Healthcare Provider Details

I. General information

NPI: 1184080012
Provider Name (Legal Business Name): KELLY MATTHAEI AGPCNP-BC, ACCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 FROST ST
SAN DIEGO CA
92123-2701
US

IV. Provider business mailing address

16309 OAKLEY RD
RAMONA CA
92065-4231
US

V. Phone/Fax

Practice location:
  • Phone: 858-761-2421
  • Fax:
Mailing address:
  • Phone: 760-310-9145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number4267
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95002101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: