Provider Demographics
NPI:1083950877
Name:NAKAYA AVILA, SUSAN K
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:K
Last Name:NAKAYA AVILA
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 1:115 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-2719
Mailing Address - Country:US
Mailing Address - Phone:626-289-4439
Mailing Address - Fax:
Practice Address - Street 1:115 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91775-2719
Practice Address - Country:US
Practice Address - Phone:626-289-4439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-24
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA500224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA500Medicaid