Healthcare Provider Details

I. General information

NPI: 1255718797
Provider Name (Legal Business Name): MEGAN ELIZABETH MATTINGLY APN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN ELIZABETH SMYRNIOTIS

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE # 4945
EVANSTON IL
60201
US

IV. Provider business mailing address

2650 RIDGE AVE # 4945
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-357-0127
  • Fax: 847-570-1436
Mailing address:
  • Phone: 847-357-0127
  • Fax: 847-570-1436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209012647
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209012647
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: