Provider Demographics
NPI:1962126243
Name:MATILLANO, SELWYNE JEI C (RN)
Entity type:Individual
Prefix:
First Name:SELWYNE JEI
Middle Name:C
Last Name:MATILLANO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22870 SE FIR ST APT J202
Mailing Address - Street 2:
Mailing Address - City:BLACK DIAMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98010-5147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22870 SE FIR ST APT J202
Practice Address - Street 2:
Practice Address - City:BLACK DIAMOND
Practice Address - State:WA
Practice Address - Zip Code:98010-5147
Practice Address - Country:US
Practice Address - Phone:808-359-1920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61300874163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse