Provider Demographics
NPI:1356540017
Name:AYALA, THERESA ANN (NP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:AYALA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MENANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12204-2505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1125 BROADWAY
Practice Address - Street 2:HEALTH OFFICE
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-2505
Practice Address - Country:US
Practice Address - Phone:518-433-3739
Practice Address - Fax:518-471-7973
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335342363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily