Basic Information
| Provider Information | |||||||||
| NPI: | 1821324039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORLEY | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | CAROL | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 363 MAIN ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940631729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503069490 | ||||||||
| FaxNumber: | 6503069355 | ||||||||
| Practice Location | |||||||||
| Address1: | 363 MAIN ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940631729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503069490 | ||||||||
| FaxNumber: | 6503069355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2009 | ||||||||
| LastUpdateDate: | 10/22/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 7387 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.