Provider Demographics
NPI:1932691391
Name:MATAILO, PEGGY SUE (LPN)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUE
Last Name:MATAILO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:SUE
Other - Last Name:MEADOWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1501 PRAY BLVD APT E111
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-8782
Mailing Address - Country:US
Mailing Address - Phone:914-471-6349
Mailing Address - Fax:
Practice Address - Street 1:1501 PRAY BLVD APT E111
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-8782
Practice Address - Country:US
Practice Address - Phone:914-471-6349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376J00000X
NY315542-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376J00000XNursing Service Related ProvidersHomemaker