Provider Demographics
NPI:1518209808
Name:STALLWORTH, JAYRITA
Entity Type:Individual
Prefix:
First Name:JAYRITA
Middle Name:
Last Name:STALLWORTH
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 1:701 VAN ERT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-4023
Mailing Address - Country:US
Mailing Address - Phone:702-600-5055
Mailing Address - Fax:
Practice Address - Street 1:701 VAN ERT AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-4023
Practice Address - Country:US
Practice Address - Phone:702-600-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner