Provider Demographics
NPI:1093261547
Name:MATTICE, KAITLIN ROSE (NP)
Entity Type:Individual
Prefix:MS
First Name:KAITLIN
Middle Name:ROSE
Last Name:MATTICE
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 1:861 N VISTA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-7518
Mailing Address - Country:US
Mailing Address - Phone:402-990-8438
Mailing Address - Fax:
Practice Address - Street 1:127 S SAN VICENTE BLVD
Practice Address - Street 2:SUITE A3600
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-3311
Practice Address - Country:US
Practice Address - Phone:310-423-8317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004784363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care