Provider Demographics
NPI:1366062242
Name:MATA, VERONICA TREJO (LVN)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:TREJO
Last Name:MATA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:PROF
Other - First Name:VERONICA
Other - Middle Name:TREJO
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:305 N COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:GRAND SALINE
Mailing Address - State:TX
Mailing Address - Zip Code:75140-1403
Mailing Address - Country:US
Mailing Address - Phone:903-368-4211
Mailing Address - Fax:
Practice Address - Street 1:305 N COLLIER ST
Practice Address - Street 2:
Practice Address - City:GRAND SALINE
Practice Address - State:TX
Practice Address - Zip Code:75140-1403
Practice Address - Country:US
Practice Address - Phone:903-368-4211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT99999992084D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084D0003XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyDiagnostic NeuroimagingGroup - Multi-Specialty