Healthcare Provider Details

I. General information

NPI: 1295501286
Provider Name (Legal Business Name): KORTNEY MATHIESEN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 11/30/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 SUTTON WAY
GRASS VALLEY CA
95945-4102
US

IV. Provider business mailing address

101 MARGARET LN STE C
GRASS VALLEY CA
95945-4207
US

V. Phone/Fax

Practice location:
  • Phone: 530-477-8114
  • Fax:
Mailing address:
  • Phone: 530-477-8114
  • Fax: 530-477-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU3820
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: