Provider Demographics
NPI:1720964869
Name:KATES-MATTHEW, TIANNA GEORGIA
Entity type:Individual
Prefix:
First Name:TIANNA
Middle Name:GEORGIA
Last Name:KATES-MATTHEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 CANTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06092
Mailing Address - Country:US
Mailing Address - Phone:914-512-4107
Mailing Address - Fax:
Practice Address - Street 1:52 CANTON RD
Practice Address - Street 2:
Practice Address - City:WEST SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06092
Practice Address - Country:US
Practice Address - Phone:914-512-4107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCTNY91310664E376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty