Provider Demographics
NPI:1326314824
Name:MATTINGLY, JEANNIE MARIA (APRN)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:MARIA
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S MAIN CROSS ST
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-1065
Mailing Address - Country:US
Mailing Address - Phone:606-638-0938
Mailing Address - Fax:859-813-5394
Practice Address - Street 1:125 S MAIN CROSS ST
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1065
Practice Address - Country:US
Practice Address - Phone:606-638-0938
Practice Address - Fax:859-813-5394
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007362363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100233430Medicaid