Provider Demographics
NPI:1447304001
Name:FAVELA, CORRINE A (NP)
Entity type:Individual
Prefix:
First Name:CORRINE
Middle Name:A
Last Name:FAVELA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CORRINE
Other - Middle Name:A
Other - Last Name:PORRAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:9209 COLIMA RD
Mailing Address - Street 2:STE 1000
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90605-1813
Mailing Address - Country:US
Mailing Address - Phone:562-696-1104
Mailing Address - Fax:
Practice Address - Street 1:11525 BROOKSHIRE AVE STE 301
Practice Address - Street 2:ATTN MAGGIE NOLES MS 6160
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4982
Practice Address - Country:US
Practice Address - Phone:562-862-3684
Practice Address - Fax:562-862-7145
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP15844363L00000X
CARN570209363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA570209OtherREGISTERED NURSE LICENSE
CA2005009644-22OtherBOARD CERTIFICATION