Provider Demographics
NPI:1124891858
Name:MATTILA, KATIE ANN (NP)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN
Last Name:MATTILA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ANN
Other - Last Name:LONGENECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 FULLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1918
Mailing Address - Country:US
Mailing Address - Phone:616-336-3909
Mailing Address - Fax:616-336-8830
Practice Address - Street 1:790 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1918
Practice Address - Country:US
Practice Address - Phone:616-336-3909
Practice Address - Fax:616-336-8830
Is Sole Proprietor?:No
Enumeration Date:2023-11-03
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11177363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner