Healthcare Provider Details

I. General information

NPI: 1699715714
Provider Name (Legal Business Name): GLENDA M. YETTER N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5957 W RAMSEY ST
BANNING CA
92220-3058
US

IV. Provider business mailing address

PO BOX 10069
SAN BERNARDINO CA
92423-0069
US

V. Phone/Fax

Practice location:
  • Phone: 951-845-0313
  • Fax:
Mailing address:
  • Phone: 909-335-4188
  • Fax: 909-796-4158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5357
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: