Healthcare Provider Details

I. General information

NPI: 1043982903
Provider Name (Legal Business Name): LAUREN MARIE MATTIACE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 10/02/2021
Certification Date: 10/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 W AMADOR AVE
LAS CRUCES NM
88005-2739
US

IV. Provider business mailing address

2022 PINECONE WAY
LAS CRUCES NM
88012-6006
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-5482
  • Fax:
Mailing address:
  • Phone: 575-527-5482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number65402
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: