Provider Demographics
NPI:1063082071
Name:CORPUS, MARY JOANNE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JOANNE
Last Name:CORPUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:J
Other - Last Name:JACINTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3432 W 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-4421
Mailing Address - Country:US
Mailing Address - Phone:907-350-0390
Mailing Address - Fax:
Practice Address - Street 1:3432 W 80TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502-4421
Practice Address - Country:US
Practice Address - Phone:907-350-0390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness