Provider Demographics
NPI:1114537537
Name:MATTINGLY, CASEY LYNN
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:LYNN
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:LYNN
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP
Mailing Address - Street 1:204 KELLY ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:KY
Mailing Address - Zip Code:40361-1516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 KELLY ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:KY
Practice Address - Zip Code:40361-1516
Practice Address - Country:US
Practice Address - Phone:937-213-0571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-01
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1156767163WE0003X
KY3015429363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency