Basic Information
| Provider Information | |||||||||
| NPI: | 1477140879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYALA DE LEON | ||||||||
| FirstName: | JAQUELIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 911 N GOLIAD ST | ||||||||
| Address2: | |||||||||
| City: | ROCKWALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750872230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4694589021 | ||||||||
| FaxNumber: | 8666936509 | ||||||||
| Practice Location | |||||||||
| Address1: | 709 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | FORNEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751269148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4694589021 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2020 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-139862 | TX | Y |
No ID Information.