Provider Demographics
NPI:1609258664
Name:MATULAITIS, COLLEEN FRANCES (NP)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:FRANCES
Last Name:MATULAITIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:FRANCES
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:11101 CATHAGE RD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811
Mailing Address - Country:US
Mailing Address - Phone:410-912-6104
Mailing Address - Fax:410-912-6105
Practice Address - Street 1:11101 CATHAGE RD.
Practice Address - Street 2:SUITE 102
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-912-6104
Practice Address - Fax:410-912-6105
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR076432363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD432534YTQMedicare PIN