MEDICARE: HANNAH THERESA MATVIKO FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	28266008A	IN
2	363LF0000X	Family Nurse Practitioner	71011958A	IN
3	363LF0000X	Family Nurse Practitioner	209024267	IL

General Provider Information

NPI Number	:	1013672682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HANNAH THERESA MATVIKO FNP-C

Provider Business Mailing Address
First Line	:	380 W NORTH ST
Second Line	:
City	:	MANHATTAN
State	:	IL
Zip	:	60442-9839
Country	:	US
Telephone Number	:	815-802-0077
Fax Number	:	815-418-3005

Provider Business Practice Location Address
First Line	:	380 W NORTH ST
Second Line	:
City	:	MANHATTAN
State	:	IL
Zip	:	60442-9839
Country	:	US
Telephone Number	:	815-802-0077
Fax Number	:	815-418-3005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2021
Last Update Date	:	02/18/2025

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