Basic Information
| Provider Information | |||||||||
| NPI: | 1760710172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTLIN | ||||||||
| FirstName: | HARRIET | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1322 E MCANDREWS RD SUITE 202 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417733688 | ||||||||
| FaxNumber: | 5417733125 | ||||||||
| Practice Location | |||||||||
| Address1: | 1322 E MCANDREWS RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417733688 | ||||||||
| FaxNumber: | 5417733125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 201400209RN | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 15398 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 15398 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 201400210NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201400210NP-PP | 01 | OR | OREGON LICENSE | OTHER | 38-3990 | 01 | OR | MEDICARE PART A | OTHER | 930937095 | 01 | OR | CURRY HEALTH DISTRICT | OTHER | MM2123519 | 01 | OR | DEA CERTIFICATE | OTHER | NP 15398 | 01 | CA | NP LICENSE | OTHER | R0000ZGBDG | 01 | OR | CURRY GENERAL HOSPITAL MEDICARE PART B | OTHER | RN 389101 | 01 | CA | RN LICENSE | OTHER |