Provider Demographics
NPI:1528805900
Name:MATAWAY, KATHLEEN LUCILLE (RN, BSN, IBCLC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LUCILLE
Last Name:MATAWAY
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 OAKSBLUFF CT
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-7814
Mailing Address - Country:US
Mailing Address - Phone:248-417-9030
Mailing Address - Fax:
Practice Address - Street 1:2122 OAKSBLUFF CT
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-7814
Practice Address - Country:US
Practice Address - Phone:248-417-9030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704306769163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant