Healthcare Provider Details

I. General information

NPI: 1346176930
Provider Name (Legal Business Name): AYOMIDE BEATRICE AJALA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 FORDHAM RD
ALLSTON MA
02134-3000
US

IV. Provider business mailing address

366 PARK AVE APT B6
ORANGE NJ
07050-2846
US

V. Phone/Fax

Practice location:
  • Phone: 617-782-6460
  • Fax:
Mailing address:
  • Phone: 973-489-6902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: