Healthcare Provider Details

I. General information

NPI: 1245879980
Provider Name (Legal Business Name): SEAN R MATTINGLY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2019
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W 7TH ST
FREDERICK MD
21701-4586
US

IV. Provider business mailing address

501 W 7TH ST
FREDERICK MD
21701-4586
US

V. Phone/Fax

Practice location:
  • Phone: 301-698-8375
  • Fax:
Mailing address:
  • Phone: 301-698-8375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR215838
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: