Provider Demographics
NPI:1093989949
Name:BALLARD, NATALYA
Entity Type:Individual
Prefix:
First Name:NATALYA
Middle Name:
Last Name:BALLARD
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:PO BOX 2200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0722
Mailing Address - Country:US
Mailing Address - Phone:909-335-4148
Mailing Address - Fax:
Practice Address - Street 1:2 W FERN AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5916
Practice Address - Country:US
Practice Address - Phone:909-335-4148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant