Provider Demographics
NPI:1215048681
Name:MATTISON-KELLY, MICHELLE F (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:F
Last Name:MATTISON-KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:F
Other - Last Name:MATTISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6555 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0302
Practice Address - Country:US
Practice Address - Phone:916-536-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75193208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G751930Medicaid
CA1091569OtherGREAT WEST
CA000810807764OtherPHCS
CA1969350OtherUNITED HEALTHCARE
CA28799OtherINTERPLAN
CA90079685OtherPACIFICARE
CAMCMG116700OtherWESTERN HEALTH ADVANTAGE
CA7442156OtherAETNA
CAG75193OtherBLUE CROSS
CA1140767OtherCIGNA
CA053101OtherHEALTH NET
CA1055017OtherFIRST HEALTH
CAG75193OtherBLUE CROSS
CA053101OtherHEALTH NET