Healthcare Provider Details

I. General information

NPI: 1629587373
Provider Name (Legal Business Name): KAITLYN MARAZONI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CAMINO DEL RIO S STE 335
SAN DIEGO CA
92108-3743
US

IV. Provider business mailing address

2323 E HIGHLAND AVE UNIT 1205
PHOENIX AZ
85016-5211
US

V. Phone/Fax

Practice location:
  • Phone: 877-264-6747
  • Fax: 877-539-7730
Mailing address:
  • Phone: 760-681-7182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62605
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8802
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-39209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: