Healthcare Provider Details

I. General information

NPI: 1982364717
Provider Name (Legal Business Name): CHRISTIE-JO CAMPOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 W MAIN ST
ROCHESTER NY
14611-2335
US

IV. Provider business mailing address

835 W MAIN ST
ROCHESTER NY
14611-2335
US

V. Phone/Fax

Practice location:
  • Phone: 585-467-2230
  • Fax:
Mailing address:
  • Phone: 585-467-2230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCRPA-P-5645
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: