Provider Demographics
NPI:1891949160
Name:AVILA, GUADALUPE P (GUADALUPE AVILA)
Entity Type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:P
Last Name:AVILA
Suffix:
Gender:F
Credentials:GUADALUPE AVILA
Other - Prefix:
Other - First Name:GUADALUPE
Other - Middle Name:
Other - Last Name:AVILA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:GUADALUPE AVILA
Mailing Address - Street 1:3225 90TH ST APT 408
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11369-2306
Mailing Address - Country:US
Mailing Address - Phone:917-907-4737
Mailing Address - Fax:
Practice Address - Street 1:3225 90TH ST
Practice Address - Street 2:APT 408
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11369-2356
Practice Address - Country:US
Practice Address - Phone:917-907-4737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055836-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY34200OtherFLUSHING HOSPITAL
NY46300OtherPERSONAL TOUCH