Provider Demographics
NPI:1780115352
Name:DEMATTOS, KELLY ANN (MA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:DEMATTOS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4096 MERRIMAN LOOP
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-5217
Mailing Address - Country:US
Mailing Address - Phone:517-672-8309
Mailing Address - Fax:
Practice Address - Street 1:4096 MERRIMAN LOOP
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-5217
Practice Address - Country:US
Practice Address - Phone:517-672-8309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker