Provider Demographics
NPI:1003171208
Name:CHRISELLE, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:CHRISELLE
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 1:2725 PAVILION PKWY APT 3314
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-9601
Mailing Address - Country:US
Mailing Address - Phone:209-640-8625
Mailing Address - Fax:
Practice Address - Street 1:2115 HIGH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-4335
Practice Address - Country:US
Practice Address - Phone:510-536-4684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003171208Medicaid