Provider Demographics
NPI:1114614534
Name:MARTELLA, CORRI ELISE (RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:CORRI
Middle Name:ELISE
Last Name:MARTELLA
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 TWIN CITIES RD
Mailing Address - Street 2:STE 20 PMB 154
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632
Mailing Address - Country:US
Mailing Address - Phone:559-972-7200
Mailing Address - Fax:
Practice Address - Street 1:13808 MONTFORT AVE
Practice Address - Street 2:
Practice Address - City:HERALD
Practice Address - State:CA
Practice Address - Zip Code:95638-9785
Practice Address - Country:US
Practice Address - Phone:559-972-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95071234163W00000X
L-307969174N00000X
374J00000X
CAL-307969163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula