Provider Demographics
NPI:1598483646
Name:KOYILLA, MATILDA K (FNP)
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:K
Last Name:KOYILLA
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 1:4703 S PEARL DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-6073
Mailing Address - Country:US
Mailing Address - Phone:419-392-3400
Mailing Address - Fax:
Practice Address - Street 1:4703 S PEARL DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-6073
Practice Address - Country:US
Practice Address - Phone:419-392-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ278576363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ278576OtherRNP NUMBER