Healthcare Provider Details

I. General information

NPI: 1588949341
Provider Name (Legal Business Name): TRACEY RENEE MATTIO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 E 3RD ST
EDGARD LA
70049-2450
US

IV. Provider business mailing address

1115 WEBER ST
FRANKLIN LA
70538-4124
US

V. Phone/Fax

Practice location:
  • Phone: 985-497-8726
  • Fax: 985-497-3108
Mailing address:
  • Phone: 337-828-2550
  • Fax: 337-355-2335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP06635
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: