Provider Demographics
NPI:1457361867
Name:MATTIOLI, NANCY M (NP)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:M
Last Name:MATTIOLI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8933 ACTIVITY RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4427
Mailing Address - Country:US
Mailing Address - Phone:858-653-6095
Mailing Address - Fax:
Practice Address - Street 1:8933 ACTIVITY RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4427
Practice Address - Country:US
Practice Address - Phone:858-653-6095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN307368363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN307368Medicaid
CARN307368Medicaid
CAP37163Medicare UPIN