Basic Information
| Provider Information | |||||||||
| NPI: | 1093282634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AYALA | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | DNP, APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | W180N8085 TOWN HALL RD | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530513518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522511000 | ||||||||
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| Practice Location | |||||||||
| Address1: | W180N8085 TOWN HALL RD | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530513518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622511000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 8788-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LP2300X | 8788 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1093282634 | 05 | WI | MEDICAID |