Provider Demographics
NPI:1952362212
Name:MATISCO, KALYNN BROWN (APRN)
Entity Type:Individual
Prefix:DR
First Name:KALYNN
Middle Name:BROWN
Last Name:MATISCO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6717 NW 11TH PL STE B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4233
Mailing Address - Country:US
Mailing Address - Phone:352-505-0255
Mailing Address - Fax:352-505-0997
Practice Address - Street 1:6717 NW 11TH PL STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4233
Practice Address - Country:US
Practice Address - Phone:352-505-0255
Practice Address - Fax:352-505-0997
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1068572363LA2100X
FL1068572363LA2100X, 363LA2200X, 363LF0000X, 364SC0200X
FLAPRN1068572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305534500Medicaid
FL302561600Medicaid
FLE2162ZMedicare NSC
FLS74521Medicare UPIN
FL302561600Medicaid