Healthcare Provider Details

I. General information

NPI: 1730645300
Provider Name (Legal Business Name): ANGELINA HARAYDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 WELLS ST
LAS CRUCES NM
88003-1304
US

IV. Provider business mailing address

311 E 5TH ST
TUCSON AZ
85705-8413
US

V. Phone/Fax

Practice location:
  • Phone: 520-449-1774
  • Fax:
Mailing address:
  • Phone: 520-449-1774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: