Provider Demographics
NPI:1902299522
Name:MATTINGLY, VONDA BROCK (APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:VONDA
Middle Name:BROCK
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DEARBORN RD
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-8836
Mailing Address - Country:US
Mailing Address - Phone:978-998-6821
Mailing Address - Fax:
Practice Address - Street 1:10 DEARBORN RD
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-8836
Practice Address - Country:US
Practice Address - Phone:978-998-6821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1102923163W00000X
KY3009289363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse