Provider Demographics
NPI:1417555442
Name:AYALA, LAUREN ASHLEY (PTA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:AYALA
Suffix:
Gender:F
Credentials:PTA
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 876
Mailing Address - Street 2:
Mailing Address - City:YUCCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86438-0876
Mailing Address - Country:US
Mailing Address - Phone:928-486-7369
Mailing Address - Fax:
Practice Address - Street 1:3131 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-0951
Practice Address - Country:US
Practice Address - Phone:928-718-0718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPTA13169225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant