Provider Demographics
NPI:1205323128
Name:CORRAL, NANCY
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:CORRAL
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 1:1215 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-5726
Mailing Address - Country:US
Mailing Address - Phone:510-710-4636
Mailing Address - Fax:
Practice Address - Street 1:1215 53RD AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-5726
Practice Address - Country:US
Practice Address - Phone:510-710-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00091540Medicaid