Provider Demographics
NPI:1780459057
Name:CORPUS LOPEZ, DAISY DORALI
Entity type:Individual
Prefix:
First Name:DAISY
Middle Name:DORALI
Last Name:CORPUS LOPEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12466 AVENUE 415
Mailing Address - Street 2:
Mailing Address - City:OROSI
Mailing Address - State:CA
Mailing Address - Zip Code:93647-2116
Mailing Address - Country:US
Mailing Address - Phone:559-419-3612
Mailing Address - Fax:
Practice Address - Street 1:4441 E CESAR CHAVEZ BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-9171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA733649164W00000X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse