Provider Demographics
NPI:1114484417
Name:MATLOCK, ALEX ELAINE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:ALEX
Middle Name:ELAINE
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SHACKLEFORD DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2858
Mailing Address - Country:US
Mailing Address - Phone:501-500-5001
Mailing Address - Fax:
Practice Address - Street 1:6 SHACKLEFORD DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2858
Practice Address - Country:US
Practice Address - Phone:501-500-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-23
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA006101363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA006101OtherARKANSAS CERTIFIED NURSE PRACTITIONER