Provider Demographics
NPI:1629732672
Name:MATIJEGA, KELLY LYNN (CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:MATIJEGA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14453 SHADYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-3432
Mailing Address - Country:US
Mailing Address - Phone:248-408-6718
Mailing Address - Fax:
Practice Address - Street 1:19991 HALL RD STE 105
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-4254
Practice Address - Country:US
Practice Address - Phone:586-247-8609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704303979367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife