Healthcare Provider Details

I. General information

NPI: 1306758149
Provider Name (Legal Business Name): AMBRIA SHAE TAYLOR PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 S COUNTRY CLUB DR STE 19
MESA AZ
85210-9704
US

IV. Provider business mailing address

1033 S LONGMORE APT 1018
MESA AZ
85202-4339
US

V. Phone/Fax

Practice location:
  • Phone: 480-629-5592
  • Fax:
Mailing address:
  • Phone: 574-607-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-015209
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: