MEDICARE: THERESA ANN AYALA NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F335342	NY

General Provider Information

NPI Number	:	1356540017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA ANN AYALA NP

Provider Business Mailing Address
First Line	:	1125 BROADWAY
Second Line	:
City	:	MENANDS
State	:	NY
Zip	:	12204-2505
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 BROADWAY
Second Line	:	HEALTH OFFICE
City	:	ALBANY
State	:	NY
Zip	:	12204-2505
Country	:	US
Telephone Number	:	518-433-3739
Fax Number	:	518-471-7973

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2007
Last Update Date	:	05/07/2019

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