Provider Demographics
NPI:1255874731
Name:MATTINGLY, JESSICA NICOLE (APRN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:255 ANNA LEE DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40071-9083
Mailing Address - Country:US
Mailing Address - Phone:502-216-8827
Mailing Address - Fax:
Practice Address - Street 1:7926 PRESTON HWY STE 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-964-4357
Practice Address - Fax:502-966-5948
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3010918363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100495750Medicaid