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General NPI Number Information
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NPI Number | 1861192668
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Entity Type | Individual
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Provider Name | MS. MARYLISA AYALA
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Gender | Female
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Dates
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Enumeration Date | 03/09/2023
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Last Update Date | 03/09/2023
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Provider Practice Location Address
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Address Line | 1113 COLLEGE AVE SUITE A
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City | SOUTH MILWAUKEE
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State | WI
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Zip | 53172
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Country | US
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Telephone | 414-762-8441
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Fax |
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Provider Business Mailing Address
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Address Line | 1334 MANITOBA AVE
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City | SOUTH MILWAUKEE
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State | WI
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Zip | 53172
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Country | US
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Telephone | 414-241-9174
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 11545-146
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License Number State | WI
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