Healthcare Provider Details

I. General information

NPI: 1588655617
Provider Name (Legal Business Name): VALERIE JENINE REILLY P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VALERIE JENINE REILLY P.A.

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 W TEFFT ST SUITE A
NIPOMO CA
93444-9289
US

IV. Provider business mailing address

699 W TEFFT ST SUITE A
NIPOMO CA
93444-9289
US

V. Phone/Fax

Practice location:
  • Phone: 805-930-9995
  • Fax: 805-929-5771
Mailing address:
  • Phone: 805-930-9995
  • Fax: 805-929-5771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15225
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPA15255
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: