Provider Demographics
NPI:1033670062
Name:MATTINGLY, ERA LOUISE (APN)
Entity Type:Individual
Prefix:
First Name:ERA
Middle Name:LOUISE
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11522 WHITE PINE AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-8379
Mailing Address - Country:US
Mailing Address - Phone:618-889-4834
Mailing Address - Fax:
Practice Address - Street 1:11522 WHITE PINE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-8379
Practice Address - Country:US
Practice Address - Phone:618-889-4834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-31
Last Update Date:2019-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019019363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily