Provider Demographics
NPI:1902465289
Name:AYALA, MARY ANNE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:AYALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3607 RIVERA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2415
Mailing Address - Country:US
Mailing Address - Phone:915-533-7057
Mailing Address - Fax:905-533-7158
Practice Address - Street 1:3612 PERA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2412
Practice Address - Country:US
Practice Address - Phone:905-533-7057
Practice Address - Fax:915-533-7158
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141781363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily