Provider Demographics
NPI:1962930180
Name:MATTERN, ANGELA MARIE (NP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:MATTERN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 HOLY CROSS PKWY
Mailing Address - Street 2:PROVIDER SERVICES-ENROLLMENT
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60101 BODNAR BLVD STE 100B
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-9340
Practice Address - Country:US
Practice Address - Phone:574-335-8800
Practice Address - Fax:574-335-0613
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007221A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300004473Medicaid