Provider Demographics
NPI:1750931663
Name:MATLICK, MARILYN KAY
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:KAY
Last Name:MATLICK
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 1:29050 252ND AVE
Mailing Address - Street 2:
Mailing Address - City:DUNHAM
Mailing Address - State:MO
Mailing Address - Zip Code:63438
Mailing Address - Country:US
Mailing Address - Phone:217-541-9003
Mailing Address - Fax:
Practice Address - Street 1:29050 252ND AVE
Practice Address - Street 2:
Practice Address - City:DUNHAM
Practice Address - State:MO
Practice Address - Zip Code:63438
Practice Address - Country:US
Practice Address - Phone:217-541-9003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider