1265663256 NPI number — MRS. ANN MIGNON MATTINGLY GILLIS M.ED

Table of content: MRS. ANN MIGNON MATTINGLY GILLIS M.ED (NPI 1265663256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265663256 NPI number — MRS. ANN MIGNON MATTINGLY GILLIS M.ED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTINGLY GILLIS
Provider First Name:
ANN
Provider Middle Name:
MIGNON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARTER
Provider Other First Name:
ANN
Provider Other Middle Name:
MIGNON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1265663256
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 N PALAFOX ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32501-2664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-266-2724
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5642 JONES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32570-2304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-626-7779
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH15063 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 021826100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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