Provider Demographics
NPI:1184080012
Name:MATTHAEI, KELLY (AGPCNP-BC, ACCNS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MATTHAEI
Suffix:
Gender:F
Credentials:AGPCNP-BC, ACCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16309 OAKLEY RD
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-4231
Mailing Address - Country:US
Mailing Address - Phone:760-310-9145
Mailing Address - Fax:
Practice Address - Street 1:9834 GENESEE AVE STE 411
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1264
Practice Address - Country:US
Practice Address - Phone:760-310-9145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002101363L00000X
CA4267364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care