Healthcare Provider Details

I. General information

NPI: 1689511172
Provider Name (Legal Business Name): CAITLIN MARIE MATTA RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 GRUMMAN ST
ANCHORAGE AK
99507-1516
US

IV. Provider business mailing address

4750 GRUMMAN ST
ANCHORAGE AK
99507-1516
US

V. Phone/Fax

Practice location:
  • Phone: 907-602-0276
  • Fax:
Mailing address:
  • Phone: 907-602-0276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number189675
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: