Healthcare Provider Details

I. General information

NPI: 1942500376
Provider Name (Legal Business Name): SHANA LEIGH MATLYAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 08/30/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 WINTER ST
PEMBROKE MA
02359-4965
US

IV. Provider business mailing address

24 BAYLEY TER
WEYMOUTH MA
02190-1756
US

V. Phone/Fax

Practice location:
  • Phone: 781-312-1393
  • Fax:
Mailing address:
  • Phone: 781-812-7917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN10021630
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: