Provider Demographics
NPI:1629638390
Name:AYALA, CARLOS M (RN)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:M
Last Name:AYALA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2290 CAMINITO PESCADO UNIT 51
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-1954
Mailing Address - Country:US
Mailing Address - Phone:619-243-9147
Mailing Address - Fax:
Practice Address - Street 1:2290 CAMINITO PESCADO UNIT 51
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-1954
Practice Address - Country:US
Practice Address - Phone:619-243-9147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-15
Last Update Date:2019-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95192524163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse