Provider Demographics
NPI:1457040818
Name:MATTINGLY, IRENA (AGNP-C)
Entity type:Individual
Prefix:
First Name:IRENA
Middle Name:
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:IRENA
Other - Middle Name:
Other - Last Name:GOCHENOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6812 SE DREW ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-1830
Mailing Address - Country:US
Mailing Address - Phone:503-707-4064
Mailing Address - Fax:
Practice Address - Street 1:6214 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5417
Practice Address - Country:US
Practice Address - Phone:503-908-6616
Practice Address - Fax:225-351-9980
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10007639363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care