Provider Demographics
NPI:1134483084
Name:BAALLA, KETTY ALEXANDRIA (BA)
Entity Type:Individual
Prefix:MS
First Name:KETTY
Middle Name:ALEXANDRIA
Last Name:BAALLA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MS
Other - First Name:KETTY
Other - Middle Name:ALEXANDRIA
Other - Last Name:NAZARIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:80 E END AVE
Mailing Address - Street 2:CLARKE SCHOOL NEW YORK
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-8004
Mailing Address - Country:US
Mailing Address - Phone:212-585-3500
Mailing Address - Fax:
Practice Address - Street 1:80 E END AVE
Practice Address - Street 2:CLARKE SCHOOL NEW YORK
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-8004
Practice Address - Country:US
Practice Address - Phone:212-585-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16757171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16757OtherSERVICE COORDINATION ID