Provider Demographics
NPI:1902873912
Name:MATTINGLY, CATHERINE FAYE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:FAYE
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BUTTERNUT DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4655
Mailing Address - Country:US
Mailing Address - Phone:864-298-2826
Mailing Address - Fax:864-672-7764
Practice Address - Street 1:2001 E GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1529
Practice Address - Country:US
Practice Address - Phone:864-332-3098
Practice Address - Fax:855-232-3959
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2428363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0103Medicaid
SCS94984Medicare UPIN
SCS949846526Medicare ID - Type UnspecifiedPROVIDER NUMBER