Healthcare Provider Details

I. General information

NPI: 1194449165
Provider Name (Legal Business Name): EDITH CORRALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 E 28TH ST
OAKLAND CA
94606-3268
US

IV. Provider business mailing address

1340 E 28TH ST
OAKLAND CA
94606-3268
US

V. Phone/Fax

Practice location:
  • Phone: 510-881-6232
  • Fax:
Mailing address:
  • Phone: 510-881-6232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: