Provider Demographics
NPI:1558017590
Name:AYALA, ALEXIS
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:AYALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 E WRIGHTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-2627
Mailing Address - Country:US
Mailing Address - Phone:630-770-0320
Mailing Address - Fax:
Practice Address - Street 1:224 E WRIGHTWOOD AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-2627
Practice Address - Country:US
Practice Address - Phone:630-770-0320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer