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General NPI Number Information
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NPI Number | 1295414951
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Entity Type | Individual
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Provider Name | NICOLE MARIE MATOS
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Gender | Female
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Dates
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Enumeration Date | 07/11/2023
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Last Update Date | 07/11/2023
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Provider Practice Location Address
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Address Line | 2447 SUMMERFIELD RD
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City | SANTA ROSA
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State | CA
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Zip | 95405-7815
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Country | US
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Telephone | 707-800-3962
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Fax | 707-581-2154
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Provider Business Mailing Address
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Address Line | 19765 HIGHWAY 116
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City | MONTE RIO
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State | CA
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Zip | 95462-9718
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Country | US
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Telephone | 415-602-6704
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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