Healthcare Provider Details

I. General information

NPI: 1306591367
Provider Name (Legal Business Name): MIRRIAM C MATULULA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 WEYMAN RD
PITTSBURGH PA
15236-1584
US

IV. Provider business mailing address

333 N SUMMIT ST FL 15
TOLEDO OH
43604-1531
US

V. Phone/Fax

Practice location:
  • Phone: 800-427-1902
  • Fax:
Mailing address:
  • Phone:
  • Fax: 800-564-5952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number2019050903
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF10210486
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: