Healthcare Provider Details

I. General information

NPI: 1265849053
Provider Name (Legal Business Name): THERESA KATHERINE MATTINGLY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3265 NE RALPH POWELL RD
LEES SUMMIT MO
64064-2301
US

IV. Provider business mailing address

3265 NE RALPH POWELL RD
LEES SUMMIT MO
64064-2301
US

V. Phone/Fax

Practice location:
  • Phone: 816-524-4747
  • Fax: 816-524-4929
Mailing address:
  • Phone: 816-524-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number125064953
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: