Provider Demographics
NPI:1508557000
Name:MATTIE, AMY MICHELLE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:MATTIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 E STROOP RD
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-4926
Mailing Address - Country:US
Mailing Address - Phone:937-294-2651
Mailing Address - Fax:
Practice Address - Street 1:1320 E STROOP RD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-4926
Practice Address - Country:US
Practice Address - Phone:937-294-2951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09201148183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician