Healthcare Provider Details

I. General information

NPI: 1124292701
Provider Name (Legal Business Name): MONA MARCELLA COLIANNO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST MLG CLR 1
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

1ST MLG CLR 1
CAMP PENDLETON CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1457
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A9720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: