Provider Demographics
NPI:1407395239
Name:MATUA, KENNEDY
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:
Last Name:MATUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E 450 S
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-1736
Mailing Address - Country:US
Mailing Address - Phone:801-776-3305
Mailing Address - Fax:801-774-9594
Practice Address - Street 1:430 E 450 S
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-1736
Practice Address - Country:US
Practice Address - Phone:801-776-3305
Practice Address - Fax:801-774-9594
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker