Provider Demographics
NPI:1982448015
Name:MATLOCK, KRISTINA STARR
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:STARR
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 PROSPECT DR
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1142
Mailing Address - Country:US
Mailing Address - Phone:216-203-8531
Mailing Address - Fax:
Practice Address - Street 1:2440 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-1142
Practice Address - Country:US
Practice Address - Phone:216-203-8531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95228847363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner