Healthcare Provider Details

I. General information

NPI: 1942559125
Provider Name (Legal Business Name): AYONNA PROCTER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 WILLOW RD
MENLO PARK CA
94025-3653
US

IV. Provider business mailing address

1250 WATERS PLACE SUITE 501
BRONX NY
10461
US

V. Phone/Fax

Practice location:
  • Phone: 866-839-6979
  • Fax:
Mailing address:
  • Phone: 718-409-9444
  • Fax: 718-409-0236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number292715
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number62-035520
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: