Provider Demographics
NPI:1245095819
Name:MAIELLO, CHRISTINA M
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:M
Last Name:MAIELLO
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 1:651 CORTE DE QUINTERO
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-8340
Mailing Address - Country:US
Mailing Address - Phone:805-796-2558
Mailing Address - Fax:
Practice Address - Street 1:1910 OUTLET CENTER DR
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0677
Practice Address - Country:US
Practice Address - Phone:805-485-2400
Practice Address - Fax:805-485-3025
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant