Healthcare Provider Details

I. General information

NPI: 1881682052
Provider Name (Legal Business Name): CATHERINE FAYE MATTIE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56TH MEDICAL GROUP 7219 LITCHFIELD ROAD
LUKE AIR FORCE BASE AZ
85309-1525
US

IV. Provider business mailing address

14303 W AMELIA AVE
GOODYEAR AZ
85338-8444
US

V. Phone/Fax

Practice location:
  • Phone: 623-856-4032
  • Fax: 623-856-8803
Mailing address:
  • Phone: 623-856-9708
  • Fax: 623-856-8255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberARNP9167047
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: