Healthcare Provider Details

I. General information

NPI: 1568487098
Provider Name (Legal Business Name): TAMI JOY MATUSZAK APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 LONDON RD STE 102
DULUTH MN
55812-1787
US

IV. Provider business mailing address

400 E 3RD ST
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 218-576-0100
  • Fax: 218-576-0126
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR131351-8
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2983
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: