Provider Demographics
NPI:1235867623
Name:MATTIMOE, KELLY RENE (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENE
Last Name:MATTIMOE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 N WASHINGTON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4436
Mailing Address - Country:US
Mailing Address - Phone:432-332-9263
Mailing Address - Fax:432-332-9264
Practice Address - Street 1:612 N WASHINGTON AVE STE 200
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4436
Practice Address - Country:US
Practice Address - Phone:432-332-9263
Practice Address - Fax:432-332-9264
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1085712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily