Provider Demographics
NPI:1659998649
Name:CAMARILLO, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:CAMARILLO
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 1:4545 GEORGETOWN PL STE D
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6229
Mailing Address - Country:US
Mailing Address - Phone:209-269-5587
Mailing Address - Fax:
Practice Address - Street 1:4545 GEORGETOWN PL STE D
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6229
Practice Address - Country:US
Practice Address - Phone:209-269-5587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA700371164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse