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
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-9490
Mailing Address - Country:US
Mailing Address - Phone:209-640-8625
Mailing Address - Fax:
Practice Address - Street 1:4709 PALOMINO WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-9309
Practice Address - Country:US
Practice Address - Phone:925-206-4791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003171208Medicaid