Provider Demographics
NPI:1730731597
Name:STREET, MATTIE VINCENTNETTA (PATIENT CARE ASSOCIA)
Entity type:Individual
Prefix:MRS
First Name:MATTIE
Middle Name:VINCENTNETTA
Last Name:STREET
Suffix:
Gender:F
Credentials:PATIENT CARE ASSOCIA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1773 LATTIMER DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-2567
Mailing Address - Country:US
Mailing Address - Phone:614-604-2435
Mailing Address - Fax:
Practice Address - Street 1:762 CONESTOGA DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2616
Practice Address - Country:US
Practice Address - Phone:614-272-4009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCHW.001230172V00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No172V00000XOther Service ProvidersCommunity Health Worker