Provider Demographics
NPI:1578013587
Name:MATTINGLY, REBEKAH LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:LYNN
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 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7906
Mailing Address - Fax:615-920-8938
Practice Address - Street 1:525 TUCKER DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9182
Practice Address - Country:US
Practice Address - Phone:606-759-9921
Practice Address - Fax:606-759-9831
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010733363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK228540OtherMEDICARE
KY7100453290Medicaid