Provider Demographics
NPI:1326062316
Name:CORLEY, MARY ANETA (RN, CFNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANETA
Last Name:CORLEY
Suffix:
Gender:F
Credentials:RN, CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 TECHNOLOGY CTR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2697
Mailing Address - Country:US
Mailing Address - Phone:903-247-0484
Mailing Address - Fax:903-247-0485
Practice Address - Street 1:123 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LONE STAR
Practice Address - State:TX
Practice Address - Zip Code:75668-2223
Practice Address - Country:US
Practice Address - Phone:903-656-0633
Practice Address - Fax:903-656-0636
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX437214363LF0000X
TXAP107303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092119904Medicaid
TX092119903Medicaid
TXNP7061OtherBCBS FAMILY PRACTICE
TX092119904Medicaid
TXNP0030Medicare ID - Type UnspecifiedFAMILY PRACTICE
TX092119903Medicaid