Provider Demographics
NPI:1265663256
Name:MATTINGLY GILLIS, ANN MIGNON (MED)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:MIGNON
Last Name:MATTINGLY GILLIS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:MIGNON
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1300 N PALAFOX ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-2664
Mailing Address - Country:US
Mailing Address - Phone:850-266-2724
Mailing Address - Fax:
Practice Address - Street 1:5642 JONES ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-2304
Practice Address - Country:US
Practice Address - Phone:850-626-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15063101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health