Provider Demographics
NPI:1154057404
Name:MATTINGLY, JONATHAN LEE (LPN)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:LEE
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11531 SUNDERLAND RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-8274
Mailing Address - Country:US
Mailing Address - Phone:618-964-5139
Mailing Address - Fax:
Practice Address - Street 1:11531 SUNDERLAND RD # A
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-8274
Practice Address - Country:US
Practice Address - Phone:618-534-3624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.118516164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse