Provider Demographics
NPI:1992236178
Name:MATENGO, MAUREEN
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:MATENGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4949 LIBERTY LN
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18106-9014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4949 LIBERTY LN
Practice Address - Street 2:SUITE 210
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106-9014
Practice Address - Country:US
Practice Address - Phone:484-560-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATLRN049525163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102888687Medicaid