Provider Demographics
NPI:1497124192
Name:MATTESON, LYNNETTE M (NP)
Entity Type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:M
Last Name:MATTESON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 E MAIN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PETERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47567-1270
Mailing Address - Country:US
Mailing Address - Phone:812-354-8426
Mailing Address - Fax:812-354-9134
Practice Address - Street 1:611 E MAIN STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:PETERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47567-1270
Practice Address - Country:US
Practice Address - Phone:812-354-8426
Practice Address - Fax:812-354-9134
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71005820A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201322180Medicaid
IN000000984156OtherANTHEM
IN201322180Medicaid