Provider Demographics
NPI:1316672439
Name:ESCOBEDO, MAMIE CORRINA
Entity type:Individual
Prefix:
First Name:MAMIE
Middle Name:CORRINA
Last Name:ESCOBEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2370 SKYWAY DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1133
Mailing Address - Country:US
Mailing Address - Phone:805-554-3312
Mailing Address - Fax:805-347-6953
Practice Address - Street 1:2370 SKYWAY DR STE 104
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1133
Practice Address - Country:US
Practice Address - Phone:805-554-3305
Practice Address - Fax:805-347-6953
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker