Provider Demographics
NPI:1417569559
Name:MATTISON, MANDY (MSN-ED, RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:MATTISON
Suffix:
Gender:F
Credentials:MSN-ED, RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 SE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-5445
Mailing Address - Country:US
Mailing Address - Phone:623-330-1695
Mailing Address - Fax:
Practice Address - Street 1:1406 MARINE DR
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3808
Practice Address - Country:US
Practice Address - Phone:509-539-3985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201604495RN163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant