Provider Demographics
NPI:1215579453
Name:MATULICH, KAILEY ANNE
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:ANNE
Last Name:MATULICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAILEY
Other - Middle Name:ANNE
Other - Last Name:LOCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19918 DAMSON RD
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036
Mailing Address - Country:US
Mailing Address - Phone:425-246-6234
Mailing Address - Fax:
Practice Address - Street 1:21630 84TH AVE W
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026
Practice Address - Country:US
Practice Address - Phone:425-774-3042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider