Provider Demographics
NPI:1386379501
Name:MATUSIK, MALLORY NICHOLE (FNP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:NICHOLE
Last Name:MATUSIK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9811 W 145TH AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-7258
Mailing Address - Country:US
Mailing Address - Phone:219-484-7683
Mailing Address - Fax:
Practice Address - Street 1:519 N HALLECK ST
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9553
Practice Address - Country:US
Practice Address - Phone:219-987-7750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28229514A363LF0000X
IN71012811A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily