MEDICARE: SHANA MATATOV MSN, 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	363LF0000X	Family Nurse Practitioner	95025038	CA

General Provider Information

NPI Number	:	1922882067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA MATATOV MSN, FNP-C

Provider Business Mailing Address
First Line	:	4919 LAUREL CANYON BLVD APT 16
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-3734
Country	:	US
Telephone Number	:	310-467-0873
Fax Number	:

Provider Business Practice Location Address
First Line	:	4919 LAUREL CANYON BLVD APT 16
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-3734
Country	:	US
Telephone Number	:	310-467-0873
Fax Number	:

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

Provider Enumeration Date	:	08/21/2023
Last Update Date	:	08/21/2023

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