Provider Demographics
NPI:1013045137
Name:MATTOX, DAVIKA JON KUPER (APRN)
Entity Type:Individual
Prefix:
First Name:DAVIKA
Middle Name:JON KUPER
Last Name:MATTOX
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:321 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1671
Practice Address - Country:US
Practice Address - Phone:606-784-4161
Practice Address - Fax:606-783-9952
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1108490163W00000X
KY3008791363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000560517OtherANTHEM BCBS
KY30610026Medicaid
KY7100317090Medicaid
KY7100317090Medicaid