Provider Demographics
NPI:1396093159
Name:MATATHIA, MICHELLE LISA
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LISA
Last Name:MATATHIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HARVARD DR
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-1810
Mailing Address - Country:US
Mailing Address - Phone:516-551-4928
Mailing Address - Fax:516-367-9189
Practice Address - Street 1:140 HARVARD DR
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1810
Practice Address - Country:US
Practice Address - Phone:516-551-4928
Practice Address - Fax:516-367-9189
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY804364174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist