Provider Demographics
NPI:1962697953
Name:MATTINGLY, JOANNE D (APNP)
Entity type:Individual
Prefix:MS
First Name:JOANNE
Middle Name:D
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:M
Other - Last Name:DELUCA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:GENERAL SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5800
Mailing Address - Fax:414-805-5809
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:GENERAL SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5800
Practice Address - Fax:414-805-5809
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI142757363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1962697953Medicaid
WI102473601Medicare PIN