Provider Demographics
NPI:1174192512
Name:VILLACORTA, GEORGINA LAUS (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:GEORGINA
Middle Name:LAUS
Last Name:VILLACORTA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4070 JURUPA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2234
Mailing Address - Country:US
Mailing Address - Phone:951-808-2422
Mailing Address - Fax:
Practice Address - Street 1:8070 JURUPA AVENUE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:155-499-1933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA606009163W00000X
CA95020330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse