Provider Demographics
NPI:1023559259
Name:CAMILON, MARINELLE
Entity Type:Individual
Prefix:
First Name:MARINELLE
Middle Name:
Last Name:CAMILON
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 1:1509 WILSON TERRACE DRIVE
Mailing Address - Street 2:REHAB BUILDING, GROUND FLOOR, RM 7G03
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4007
Mailing Address - Country:US
Mailing Address - Phone:858-349-6454
Mailing Address - Fax:
Practice Address - Street 1:1509 WILSON TERRACE DRIVE
Practice Address - Street 2:REHAB BUILDING, GROUND FLOOR, RM 7G03
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:858-349-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A16764207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty