Provider Demographics
NPI:1548612138
Name:MATTINGLY, KOURTNEY E (NP)
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:E
Last Name:MATTINGLY
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:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1510
Mailing Address - Country:US
Mailing Address - Phone:812-450-3201
Mailing Address - Fax:812-450-3395
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710
Practice Address - Country:US
Practice Address - Phone:812-450-3201
Practice Address - Fax:812-450-4560
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006526A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner