Provider Demographics
NPI:1255878476
Name:AYALA, TAHISHA EVIT
Entity type:Individual
Prefix:MS
First Name:TAHISHA
Middle Name:EVIT
Last Name:AYALA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TAHISHA
Other - Middle Name:EVIT
Other - Last Name:AYALA-DEAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11507 LINDEN BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-1908
Mailing Address - Country:US
Mailing Address - Phone:347-706-8380
Mailing Address - Fax:
Practice Address - Street 1:11507 LINDEN BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-1908
Practice Address - Country:US
Practice Address - Phone:347-706-8380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY742052174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist