Healthcare Provider Details

I. General information

NPI: 1558405969
Provider Name (Legal Business Name): REGINA MATTIES RNC NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 COMPUTER DR W
ALBANY NY
12205-1612
US

IV. Provider business mailing address

24 COMPUTER DR W
ALBANY NY
12205-1612
US

V. Phone/Fax

Practice location:
  • Phone: 518-689-7548
  • Fax: 518-489-9431
Mailing address:
  • Phone: 518-689-7548
  • Fax: 518-489-9431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF000021
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberF360021
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: