Provider Demographics
NPI:1588655617
Name:REILLY, VALERIE JENINE (PA)
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:JENINE
Last Name:REILLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VALERIE
Other - Middle Name:JENINE
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:699 W TEFFT ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9289
Mailing Address - Country:US
Mailing Address - Phone:805-930-9995
Mailing Address - Fax:805-929-5771
Practice Address - Street 1:699 W TEFFT ST
Practice Address - Street 2:SUITE A
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9289
Practice Address - Country:US
Practice Address - Phone:805-930-9995
Practice Address - Fax:805-929-5771
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15255Medicaid
CAWPA15225AMedicare PIN
CAPOO409340Medicare PIN