Provider Demographics
NPI:1144858937
Name:DE MATTEO, DOMINIQUE ELIZABETH (NP)
Entity type:Individual
Prefix:MISS
First Name:DOMINIQUE
Middle Name:ELIZABETH
Last Name:DE MATTEO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SIDEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3253
Mailing Address - Country:US
Mailing Address - Phone:718-873-6019
Mailing Address - Fax:
Practice Address - Street 1:108 SIDEVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3253
Practice Address - Country:US
Practice Address - Phone:718-873-6019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily