Healthcare Provider Details

I. General information

NPI: 1689581928
Provider Name (Legal Business Name): MARLA ELLEN GRAY LE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2795 CABOT DR STE 105-5
CORONA CA
92883-7377
US

IV. Provider business mailing address

11408 VALLEY OAK LN
CORONA CA
92883-4721
US

V. Phone/Fax

Practice location:
  • Phone: 714-329-7706
  • Fax:
Mailing address:
  • Phone: 714-329-7706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number9704
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: