Provider Demographics
NPI:1508040023
Name:BECKER, CORLENE ALETA (RN)
Entity Type:Individual
Prefix:
First Name:CORLENE
Middle Name:ALETA
Last Name:BECKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:GENESEE
Mailing Address - State:ID
Mailing Address - Zip Code:83832
Mailing Address - Country:US
Mailing Address - Phone:208-285-1178
Mailing Address - Fax:
Practice Address - Street 1:2301 KRIER RD
Practice Address - Street 2:
Practice Address - City:GENESEE
Practice Address - State:ID
Practice Address - Zip Code:83832
Practice Address - Country:US
Practice Address - Phone:208-285-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-16760163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805589100Medicaid