Healthcare Provider Details

I. General information

NPI: 1124891858
Provider Name (Legal Business Name): KATIE ANN MATTILA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE ANN LONGENECKER

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-3909
  • Fax: 616-336-8830
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number204623
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11177
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: