Provider Demographics
NPI:1386931178
Name:MATTI, ABIMBOLA ADENIKE (CNP)
Entity type:Individual
Prefix:MS
First Name:ABIMBOLA
Middle Name:ADENIKE
Last Name:MATTI
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5376 SUNWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-4216
Mailing Address - Country:US
Mailing Address - Phone:612-515-3737
Mailing Address - Fax:
Practice Address - Street 1:732 E LAKE ST
Practice Address - Street 2:PAIN RELIEF CENTER OF MINNESOTA
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1547
Practice Address - Country:US
Practice Address - Phone:612-516-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1209274363LA2200X
MNG0210002363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology