Provider Demographics
NPI:1679763379
Name:MATLOCK, DENISE (REGISTERED NURSE)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5734 N 65TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-2329
Mailing Address - Country:US
Mailing Address - Phone:414-534-1493
Mailing Address - Fax:419-828-6586
Practice Address - Street 1:5734 N 65TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-2329
Practice Address - Country:US
Practice Address - Phone:414-534-1493
Practice Address - Fax:419-828-6586
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-28
Last Update Date:2007-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39970600Medicaid