Provider Demographics
NPI:1982367652
Name:MATLOCK, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:MATLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:545 ELM ST
Mailing Address - Street 2:
Mailing Address - City:SOUR LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:77659-2839
Mailing Address - Country:US
Mailing Address - Phone:432-215-0636
Mailing Address - Fax:
Practice Address - Street 1:545 ELM ST
Practice Address - Street 2:
Practice Address - City:SOUR LAKE
Practice Address - State:TX
Practice Address - Zip Code:77659-2839
Practice Address - Country:US
Practice Address - Phone:432-215-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula