Healthcare Provider Details

I. General information

NPI: 1134577216
Provider Name (Legal Business Name): SHALAINE BROOKE CORBILLA DNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2016
Last Update Date: 08/14/2021
Certification Date: 08/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 1ST AVE SUITE 100
SAN DIEGO CA
92101-2033
US

IV. Provider business mailing address

1075 CAMINO DEL RIO S
SAN DIEGO CA
92108-3538
US

V. Phone/Fax

Practice location:
  • Phone: 619-881-4500
  • Fax: 619-291-0959
Mailing address:
  • Phone: 619-881-4500
  • Fax: 866-886-7824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95078056
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95018015
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: