Healthcare Provider Details

I. General information

NPI: 1245868033
Provider Name (Legal Business Name): MICHELLE H MATA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE T HELLMERS CRNA

II. Dates (important events)

Enumeration Date: 03/29/2020
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 JEFFERSON HWY
JEFFERSON LA
70121-2429
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 866-624-7637
  • Fax:
Mailing address:
  • Phone: 504-842-3755
  • Fax: 504-842-2036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number213764
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: