1770795361 NPI number — JILL RAE MATTINGLY PA-C, MMSC

Table of content: JILL RAE MATTINGLY PA-C, MMSC (NPI 1770795361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770795361 NPI number — JILL RAE MATTINGLY PA-C, MMSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTINGLY
Provider First Name:
JILL
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C, MMSC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770795361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
586 MOUNTAIN PARK TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30087-5709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-469-6903
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 HUGH HOWELL RD
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
TUCKER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30084-4723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-534-1715
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2007

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: 363A00000X , with the licence number:  3283 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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