Healthcare Provider Details

I. General information

NPI: 1962853804
Provider Name (Legal Business Name): MRS. VERONICA MATLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 N CAMDEN DR STE 610
BEVERLY HILLS CA
90210-4416
US

IV. Provider business mailing address

2408 COBHAM CT
LOS ANGELES CA
90077-1330
US

V. Phone/Fax

Practice location:
  • Phone: 310-859-9052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95004115
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: