Provider Demographics
NPI:1750860367
Name:DA MATA, CHRISTAL LOUISE (FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:CHRISTAL
Middle Name:LOUISE
Last Name:DA MATA
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:CHRISTAL
Other - Middle Name:LOUISE
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:397 SW BELMONT CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7103
Mailing Address - Country:US
Mailing Address - Phone:279-718-8835
Mailing Address - Fax:772-673-8440
Practice Address - Street 1:21301 POWERLINE RD STE 103
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-2389
Practice Address - Country:US
Practice Address - Phone:561-235-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704263161363LF0000X, 363LP0808X
FLAPRN11016039363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000000OtherNONE