Provider Demographics
NPI:1407878259
Name:MATTHEWS, KATHLEEN J (ANP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 N KNIK ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7049
Mailing Address - Country:US
Mailing Address - Phone:907-376-9500
Mailing Address - Fax:907-376-9507
Practice Address - Street 1:491 N KNIK ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7049
Practice Address - Country:US
Practice Address - Phone:907-376-9500
Practice Address - Fax:907-376-9507
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK407364SP0809X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
152068Medicare ID - Type Unspecified