Provider Demographics
NPI:1073292108
Name:MATTINGLY, ERIN KACZMAREK (IBCLC)
Entity Type:Individual
Prefix:MS
First Name:ERIN
Middle Name:KACZMAREK
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 PEMBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8638
Mailing Address - Country:US
Mailing Address - Phone:910-581-0800
Mailing Address - Fax:
Practice Address - Street 1:415 PEMBROOKE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8638
Practice Address - Country:US
Practice Address - Phone:910-581-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
MS174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula