Provider Demographics
NPI:1386710176
Name:MATTIACCIO, MICHELLE A (APRN BC)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:A
Last Name:MATTIACCIO
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-3412
Mailing Address - Country:US
Mailing Address - Phone:203-755-8874
Mailing Address - Fax:203-597-9570
Practice Address - Street 1:88 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2509
Practice Address - Country:US
Practice Address - Phone:203-573-7500
Practice Address - Fax:203-573-6575
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003538363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health