MEDICARE: MCKENNA ANN MATTICE MSN, FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	95032116	CA

General Provider Information

NPI Number	:	1982430393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENNA ANN MATTICE MSN, FNP

Provider Business Mailing Address
First Line	:	239 CARMONA
Second Line	:
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-7633
Country	:	US
Telephone Number	:	949-412-9274
Fax Number	:

Provider Business Practice Location Address
First Line	:	239 CARMONA
Second Line	:
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-7633
Country	:	US
Telephone Number	:	949-412-9274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2024
Last Update Date	:	09/11/2024

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