Provider Demographics
NPI:1528520319
Name:SLATER, AYALA KATRINA
Entity type:Individual
Prefix:
First Name:AYALA
Middle Name:KATRINA
Last Name:SLATER
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 1:203 BEAL PKWY NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4239
Mailing Address - Country:US
Mailing Address - Phone:850-420-1835
Mailing Address - Fax:
Practice Address - Street 1:4740 PEARL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3080
Practice Address - Country:US
Practice Address - Phone:303-449-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102207805208100000X
390200000X
CO73658208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program