Provider Demographics
NPI:1366291809
Name:MATTAR, CHANTAL TIFFANY THERESE (NP)
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:TIFFANY THERESE
Last Name:MATTAR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12121 BROADSTREET AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-1550
Mailing Address - Country:US
Mailing Address - Phone:313-824-1000
Mailing Address - Fax:
Practice Address - Street 1:12121 BROADSTREET AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-1550
Practice Address - Country:US
Practice Address - Phone:313-824-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704288255363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care