Provider Demographics
NPI:1134883036
Name:MATLOCK, KARITA ROCHELLE
Entity type:Individual
Prefix:
First Name:KARITA
Middle Name:ROCHELLE
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6414 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64126-2528
Mailing Address - Country:US
Mailing Address - Phone:816-612-1206
Mailing Address - Fax:
Practice Address - Street 1:6414 E 17TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64126-2528
Practice Address - Country:US
Practice Address - Phone:816-612-1206
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
MO172V00000X
KS172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker