Healthcare Provider Details

I. General information

NPI: 1285378984
Provider Name (Legal Business Name): MAYA CAMPOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5441
US

IV. Provider business mailing address

1900 SESTRI LN APT 222
PETALUMA CA
94954-3956
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-8181
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number696407
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: