Healthcare Provider Details

I. General information

NPI: 1851793038
Provider Name (Legal Business Name): ANDREA AYALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 E 151ST ST S LOT 83
BIXBY OK
74008-4148
US

IV. Provider business mailing address

6333 E SKELLY DR
TULSA OK
74135-6106
US

V. Phone/Fax

Practice location:
  • Phone: 918-378-8307
  • Fax:
Mailing address:
  • Phone: 918-664-4224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number56864
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: