Healthcare Provider Details

I. General information

NPI: 1609258664
Provider Name (Legal Business Name): COLLEEN FRANCES MATULAITIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLLEEN FRANCES KING CRNP

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 CATHAGE RD. SUITE 102
BERLIN MD
21811
US

IV. Provider business mailing address

11101 CATHAGE RD. SUITE 102
BERLIN MD
21811
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-6104
  • Fax: 410-912-6105
Mailing address:
  • Phone: 410-912-6104
  • Fax: 410-912-6105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR076432
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: