Provider Demographics
NPI:1982394896
Name:YAGALLA, AUDREY Y
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:Y
Last Name:YAGALLA
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 1:1565 SHOEMAKER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-1030
Mailing Address - Country:US
Mailing Address - Phone:570-831-9533
Mailing Address - Fax:
Practice Address - Street 1:1565 SHOEMAKER AVE
Practice Address - Street 2:
Practice Address - City:WEST WYOMING
Practice Address - State:PA
Practice Address - Zip Code:18644-1030
Practice Address - Country:US
Practice Address - Phone:570-831-9533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency