Provider Demographics
NPI:1629393640
Name:MATTINGLY, LORRAINE FLORENCE (NP)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:FLORENCE
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 1:7222 COMMERCE CENTER DR STE 220
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2631
Mailing Address - Country:US
Mailing Address - Phone:719-650-0438
Mailing Address - Fax:719-418-2276
Practice Address - Street 1:7222 COMMERCE CENTER DR STE 220
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2631
Practice Address - Country:US
Practice Address - Phone:719-650-0438
Practice Address - Fax:719-418-2276
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2023-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0010062363LP0808X
COAPN.0010062-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000147753Medicaid