Provider Demographics
NPI:1114605060
Name:CORPUS, MAKAYLA BRIANNA
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:BRIANNA
Last Name:CORPUS
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 1:11379 POCHARD WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-2931
Mailing Address - Country:US
Mailing Address - Phone:619-905-3058
Mailing Address - Fax:
Practice Address - Street 1:10243 GENETIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-6310
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist