Provider Demographics
NPI:1669429387
Name:MATTESON-KOME, MICHELLE L (FNP/GNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:MATTESON-KOME
Suffix:
Gender:F
Credentials:FNP/GNP
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 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:101 S FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-7637
Practice Address - Country:US
Practice Address - Phone:573-884-7600
Practice Address - Fax:573-884-8200
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO132000363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206579OtherBLUE CHOICE
MO424802106Medicaid
MO433327OtherHEALTHLINK
MO433327OtherHEALTHLINK
MOP00420899Medicare PIN
MO829975236Medicare PIN
MOS88130Medicare UPIN
MO970014357Medicare PIN