Provider Demographics
NPI:1306985734
Name:MATTINGLY, LESA KEATON (RPH)
Entity type:Individual
Prefix:MRS
First Name:LESA
Middle Name:KEATON
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 RIGHT FORK LEWIS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MARTHA
Mailing Address - State:KY
Mailing Address - Zip Code:41159-8941
Mailing Address - Country:US
Mailing Address - Phone:606-652-4331
Mailing Address - Fax:
Practice Address - Street 1:412 LIBERTY ROAD
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472
Practice Address - Country:US
Practice Address - Phone:606-743-4957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY010636OtherPHARMACISTS LICENSE