Provider Demographics
NPI:1366084600
Name:MATAKIS, TAYLOR DIANNE (CPM)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:DIANNE
Last Name:MATAKIS
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:DIANNE
Other - Last Name:MUNIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LM
Mailing Address - Street 1:20 12TH ST NE
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-3812
Mailing Address - Country:US
Mailing Address - Phone:254-290-7702
Mailing Address - Fax:
Practice Address - Street 1:20 12TH ST NE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-3812
Practice Address - Country:US
Practice Address - Phone:254-290-7702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99386176B00000X
MN1082176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife