Provider Demographics
NPI:1780468470
Name:MATA, MARIE LYNN
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:LYNN
Last Name:MATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:LYNN
Other - Last Name:MAKIDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10422 DODGE RD
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48463-9766
Mailing Address - Country:US
Mailing Address - Phone:810-228-6574
Mailing Address - Fax:
Practice Address - Street 1:704 E FLINT ST
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1245
Practice Address - Country:US
Practice Address - Phone:810-228-6574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide