Provider Demographics
NPI:1679122089
Name:AYALA, IRIS CECILIA
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:CECILIA
Last Name:AYALA
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 1:2190 BOSTON RD APT 4D
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-1214
Mailing Address - Country:US
Mailing Address - Phone:917-388-7419
Mailing Address - Fax:
Practice Address - Street 1:1899 LONGFELLOW AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-4425
Practice Address - Country:US
Practice Address - Phone:347-497-6149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1312645191174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist