Provider Demographics
NPI:1932499548
Name:MATTINGLY, AMY L (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:RAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 N CAPITOL AVE
Practice Address - Street 2:NP E140
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1218
Practice Address - Country:US
Practice Address - Phone:317-962-2894
Practice Address - Fax:317-963-5285
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28169503A163W00000X
IN71003617A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201094930Medicaid
IN201094930Medicaid