Healthcare Provider Details

I. General information

NPI: 1154905982
Provider Name (Legal Business Name): GLEN WILEY APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11555 POTRERO RD
BANNING CA
92220-6946
US

IV. Provider business mailing address

1647 W PONDEROSA WAY
UPLAND CA
91784-7454
US

V. Phone/Fax

Practice location:
  • Phone: 251-849-4761
  • Fax:
Mailing address:
  • Phone: 909-697-6769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1031197
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2025038559
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017368
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: