Healthcare Provider Details

I. General information

NPI: 1144763848
Provider Name (Legal Business Name): MARI E MATTOCKS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 02/02/2021
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7232 JUSTIN WAY STE 1800
MENTOR OH
44060-4881
US

IV. Provider business mailing address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

V. Phone/Fax

Practice location:
  • Phone: 440-578-8200
  • Fax:
Mailing address:
  • Phone: 440-578-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.020206
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.372117
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: