Provider Demographics
NPI:1184648875
Name:MATLOCK, STEPHANIE M (CRNP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:M
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 MYRTLE ST STE 190
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-4604
Mailing Address - Country:US
Mailing Address - Phone:814-453-7767
Mailing Address - Fax:814-454-6667
Practice Address - Street 1:2315 MYRTLE ST STE 190
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-4604
Practice Address - Country:US
Practice Address - Phone:814-453-7767
Practice Address - Fax:814-454-6667
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP006969B363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ74955Medicare UPIN
PAP00392200OtherRR MEDICARE
PAQ74955Medicare UPIN