Provider Demographics
NPI:1790311918
Name:MATTISON, MARY LOUISE (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:MATTISON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5255 OFFICE PARK BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-3443
Mailing Address - Country:US
Mailing Address - Phone:941-755-7000
Mailing Address - Fax:941-755-7088
Practice Address - Street 1:5255 OFFICE PARK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-3443
Practice Address - Country:US
Practice Address - Phone:941-755-7000
Practice Address - Fax:941-755-7088
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11006564363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner