Provider Demographics
NPI:1124661913
Name:BAELLO, MICHAEL (MSN, APRN, FNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BAELLO
Suffix:
Gender:M
Credentials:MSN, APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3065 E OAK KNOLL LOOP
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-3872
Mailing Address - Country:US
Mailing Address - Phone:909-635-8558
Mailing Address - Fax:
Practice Address - Street 1:3065 E OAK KNOLL LOOP
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-3872
Practice Address - Country:US
Practice Address - Phone:909-635-8558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily