Provider Demographics
NPI:1083154868
Name:MATTINGLY, ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 CROAKE STATION RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40069-7335
Mailing Address - Country:US
Mailing Address - Phone:502-322-4659
Mailing Address - Fax:
Practice Address - Street 1:136 CROAKE STATION RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:KY
Practice Address - Zip Code:40069-7335
Practice Address - Country:US
Practice Address - Phone:502-322-4659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3580224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant