Healthcare Provider Details

I. General information

NPI: 1417466707
Provider Name (Legal Business Name): LIZETTE MATHIASEN PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LIZETTE MATTO PHN

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 F ST
CHULA VISTA CA
91910-3509
US

IV. Provider business mailing address

541 F ST
CHULA VISTA CA
91910-3509
US

V. Phone/Fax

Practice location:
  • Phone: 619-392-6297
  • Fax:
Mailing address:
  • Phone: 619-392-6297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number635297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: