Provider Demographics
NPI:1265699839
Name:DEMATTEO KOPF, JOANNA ROSE (RN)
Entity type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:ROSE
Last Name:DEMATTEO KOPF
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CANNON DR
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-5202
Mailing Address - Country:US
Mailing Address - Phone:631-256-6493
Mailing Address - Fax:631-256-6493
Practice Address - Street 1:12 CANNON DR
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-5202
Practice Address - Country:US
Practice Address - Phone:631-256-6493
Practice Address - Fax:631-256-6493
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY429547-1163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01261816Medicaid