Healthcare Provider Details

I. General information

NPI: 1649942715
Provider Name (Legal Business Name): STEPHANIE NICOLE MATACIA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 GEMINI PL STE 300
COLUMBUS OH
43240-6112
US

IV. Provider business mailing address

PO BOX 734439
CHICAGO IL
60673-4439
US

V. Phone/Fax

Practice location:
  • Phone: 614-383-6450
  • Fax:
Mailing address:
  • Phone: 614-383-6450
  • Fax: 614-383-6455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0027442
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.0027442
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberAPRN.CNP.0027442
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: