Provider Demographics
NPI:1417351891
Name:MATLOCK-CARR, NATOSHA LEVADA (MSN, NP-C)
Entity Type:Individual
Prefix:
First Name:NATOSHA
Middle Name:LEVADA
Last Name:MATLOCK-CARR
Suffix:
Gender:F
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-3150
Practice Address - Fax:423-224-3169
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19233363LF0000X
TN170938363L00000X
VA0024173541363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10350I5691Medicare PIN
VAVVL053B288Medicare PIN