Basic Information
| Provider Information | |||||||||
| NPI: | 1700815958 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AXTELL-KELLY | ||||||||
| FirstName: | CARYN | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2492 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917292492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095910843 | ||||||||
| FaxNumber: | 9095917226 | ||||||||
| Practice Location | |||||||||
| Address1: | 13193 CENTRAL AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | CHINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095910843 | ||||||||
| FaxNumber: | 9095917226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 03/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA17278 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA17278 | 05 | CA | MEDICAID |