Provider Demographics
NPI:1255453346
Name:MATTINGLY, LYNNETTE J (PA-C)
Entity type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:J
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:PA-C
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 7874
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85327-7874
Mailing Address - Country:US
Mailing Address - Phone:480-488-1721
Mailing Address - Fax:
Practice Address - Street 1:5128 E VILLA CASSANDRA WAY
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-9012
Practice Address - Country:US
Practice Address - Phone:480-688-6364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant