Healthcare Provider Details

I. General information

NPI: 1992004352
Provider Name (Legal Business Name): MADELINE FULCHER MATTERN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 GREEN TECH DR SUITE D
STATE COLLEGE PA
16803-2300
US

IV. Provider business mailing address

555 NITTANY RIDGE RD
HOWARD PA
16841-4162
US

V. Phone/Fax

Practice location:
  • Phone: 814-231-4043
  • Fax:
Mailing address:
  • Phone: 814-383-2461
  • Fax: 814-865-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP007526
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: