Provider Demographics
NPI:1922860907
Name:CORPUS, MARY AURAVEL FARRALES
Entity Type:Individual
Prefix:
First Name:MARY AURAVEL
Middle Name:FARRALES
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 1:51 GOLDENROD ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-3116
Mailing Address - Country:US
Mailing Address - Phone:707-863-2259
Mailing Address - Fax:
Practice Address - Street 1:51 GOLDENROD ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-3116
Practice Address - Country:US
Practice Address - Phone:707-863-2259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95199369163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse