Provider Demographics
NPI:1740881549
Name:MATLOCK, RHONDA LEA
Entity type:Individual
Prefix:
First Name:RHONDA
Middle Name:LEA
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RHONDA
Other - Middle Name:LEA
Other - Last Name:SPROUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 S SEWARD MERIDIAN PKWY # ABC
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8312
Mailing Address - Country:US
Mailing Address - Phone:907-631-3520
Mailing Address - Fax:
Practice Address - Street 1:1401 S SEWARD MERIDIAN PKWY # ABC
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8312
Practice Address - Country:US
Practice Address - Phone:907-631-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1674671Medicaid