Basic Information
| Provider Information | |||||||||
| NPI: | 1316993165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTINGLY | ||||||||
| FirstName: | TRINA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307818 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 RIVER DR | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403361272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067230399 | ||||||||
| FaxNumber: | 6067230379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 3003803 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6400 | 01 | KY | GROUP MEDICARE # | OTHER | 78901261 | 05 | KY | MEDICAID | 78009297 | 05 | KY | MEDICAID |