Provider Demographics
NPI:1316313166
Name:KING, AYANA
Entity type:Individual
Prefix:
First Name:AYANA
Middle Name:
Last Name:KING
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 1:1015 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EAST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02333-1236
Mailing Address - Country:US
Mailing Address - Phone:774-766-7763
Mailing Address - Fax:
Practice Address - Street 1:1015 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02333-1236
Practice Address - Country:US
Practice Address - Phone:774-766-7763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist