Healthcare Provider Details

I. General information

NPI: 1255975785
Provider Name (Legal Business Name): CAMILLA MARIE GELONECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 N VENTURA RD
OXNARD CA
93036-2258
US

IV. Provider business mailing address

2130 N VENTURA RD
OXNARD CA
93036-2258
US

V. Phone/Fax

Practice location:
  • Phone: 510-317-1444
  • Fax:
Mailing address:
  • Phone: 510-317-1444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number95189271
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: