Provider Demographics
NPI:1588088181
Name:MATTESON, BRECK MARIE (RN BSN IBCLC)
Entity type:Individual
Prefix:
First Name:BRECK
Middle Name:MARIE
Last Name:MATTESON
Suffix:
Gender:F
Credentials:RN BSN IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 LEGENDS ROW
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2269
Mailing Address - Country:US
Mailing Address - Phone:248-506-7474
Mailing Address - Fax:
Practice Address - Street 1:562 LEGENDS ROW
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-2269
Practice Address - Country:US
Practice Address - Phone:248-506-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704261958163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH46-4840829OtherEIN