Healthcare Provider Details

I. General information

NPI: 1386710176
Provider Name (Legal Business Name): MICHELLE A MATTIACCIO APRN BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 GRANDVIEW AVE
WATERBURY CT
06708-2509
US

IV. Provider business mailing address

4 MIDLAND RD
WATERBURY CT
06705-3412
US

V. Phone/Fax

Practice location:
  • Phone: 203-573-7500
  • Fax: 203-573-6575
Mailing address:
  • Phone: 203-755-8874
  • Fax: 203-597-9570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number003538
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: