Healthcare Provider Details

I. General information

NPI: 1417569559
Provider Name (Legal Business Name): MANDY MATTISON MSN-ED, RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 MARINE DR
ASTORIA OR
97103-3808
US

IV. Provider business mailing address

1747 SE 3RD ST
ASTORIA OR
97103-5445
US

V. Phone/Fax

Practice location:
  • Phone: 509-539-3985
  • Fax:
Mailing address:
  • Phone: 623-330-1695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number201604495RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: