Provider Demographics
NPI:1316008527
Name:MATTIJETZ, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MATTIJETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LRMC
Mailing Address - Street 2:CMR 402 BOX 0088
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180
Mailing Address - Country:DE
Mailing Address - Phone:049-6371
Mailing Address - Fax:049637-186-6419
Practice Address - Street 1:LRMC
Practice Address - Street 2:CMR 402 BOX 0088
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:DE
Practice Address - Phone:049-6371
Practice Address - Fax:049637-186-6419
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA570905163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse