1316008527 NPI number — KELLY MATTIJETZ

Table of content: KELLY MATTIJETZ (NPI 1316008527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316008527 NPI number — KELLY MATTIJETZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTIJETZ
Provider First Name:
KELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316008527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
LRMC
Provider Second Line Business Mailing Address:
CMR 402 BOX 0088
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09180
Provider Business Mailing Address Country Code:
DE
Provider Business Mailing Address Telephone Number:
0496371
Provider Business Mailing Address Fax Number:
0496371866419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
LRMC
Provider Second Line Business Practice Location Address:
CMR 402 BOX 0088
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09180
Provider Business Practice Location Address Country Code:
DE
Provider Business Practice Location Address Telephone Number:
0496371
Provider Business Practice Location Address Fax Number:
0496371866419
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  570905 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com