Provider Demographics
NPI:1316993165
Name:MATTINGLY, TRINA R (APRN)
Entity type:Individual
Prefix:
First Name:TRINA
Middle Name:R
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:APRN
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 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7818
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:417 RIVER DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1272
Practice Address - Country:US
Practice Address - Phone:606-723-0399
Practice Address - Fax:606-723-0379
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003803363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6400OtherGROUP MEDICARE #
KY78901261Medicaid
KY78009297Medicaid
KY6400OtherGROUP MEDICARE #
KYP76320Medicare UPIN
KY78009297Medicaid