Provider Demographics
NPI:1174570238
Name:MATLOCK, KELLEE (CRNA)
Entity type:Individual
Prefix:
First Name:KELLEE
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 BRECKENRIDGE DR
Mailing Address - Street 2:STE E
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-4819
Mailing Address - Country:US
Mailing Address - Phone:501-227-7797
Mailing Address - Fax:501-227-7753
Practice Address - Street 1:10301 KANIS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6205
Practice Address - Country:US
Practice Address - Phone:501-227-7797
Practice Address - Fax:501-227-7753
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC01294367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W361Medicare ID - Type Unspecified