Provider Demographics
NPI:1720860935
Name:MATLACK, KAYLENE BAY (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:KAYLENE
Middle Name:BAY
Last Name:MATLACK
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 S WORTHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BURRTON
Mailing Address - State:KS
Mailing Address - Zip Code:67020-8877
Mailing Address - Country:US
Mailing Address - Phone:620-931-8263
Mailing Address - Fax:
Practice Address - Street 1:511 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:KS
Practice Address - Zip Code:67410-2153
Practice Address - Country:US
Practice Address - Phone:785-577-8861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-017752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer