Basic Information
| Provider Information | |||||||||
| NPI: | 1457927972 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTHEWS | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | QBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8400 W CHARLESTON BLVD APT 140 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891179033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037104147 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 601 S RANCHO DR STE A10 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024374673 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2021 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | NV | Y | Other Service Providers | Contractor |
No ID Information.