Provider Demographics
NPI:1386259471
Name:MATTINGLY, ETHAN (RD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 THAD REDMAN RD
Mailing Address - Street 2:
Mailing Address - City:PAYNEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40157-7524
Mailing Address - Country:US
Mailing Address - Phone:270-496-4435
Mailing Address - Fax:
Practice Address - Street 1:175 THAD REDMAN RD
Practice Address - Street 2:
Practice Address - City:PAYNEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40157-7524
Practice Address - Country:US
Practice Address - Phone:270-496-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY164314133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered