Provider Demographics
NPI:1043982903
Name:MATTIACE, LAUREN MARIE (CNP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARIE
Last Name:MATTIACE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 PINECONE WAY
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-6006
Mailing Address - Country:US
Mailing Address - Phone:575-527-5482
Mailing Address - Fax:
Practice Address - Street 1:999 W AMADOR AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2739
Practice Address - Country:US
Practice Address - Phone:575-527-5482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM65402363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty