Basic Information
| Provider Information | |||||||||
| NPI: | 1063176543 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTA | ||||||||
| FirstName: | IBTISAM | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 RILEY AVE SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495092016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173313895 | ||||||||
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| Practice Location | |||||||||
| Address1: | 790 FULLER AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163363765 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2021 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0807X | 4704359386 | MI | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent |
No ID Information.