Provider Demographics
NPI:1679948897
Name:ZIMMERMAN, MATLYN
Entity Type:Individual
Prefix:
First Name:MATLYN
Middle Name:
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2642 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2055
Mailing Address - Country:US
Mailing Address - Phone:719-587-8323
Mailing Address - Fax:719-587-7706
Practice Address - Street 1:208 EDGEMONT BLVD
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2320
Practice Address - Country:US
Practice Address - Phone:719-587-8323
Practice Address - Fax:719-587-7706
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 38372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer