Provider Demographics
NPI:1528256583
Name:MATTHEWS, KELLY J (BS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16908 W WEYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-0840
Mailing Address - Country:US
Mailing Address - Phone:623-640-9819
Mailing Address - Fax:
Practice Address - Street 1:13055 W MCDOWELL RD. SUITE G-107
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323
Practice Address - Country:US
Practice Address - Phone:623-640-9819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0788174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist