Healthcare Provider Details

I. General information

NPI: 1306351689
Provider Name (Legal Business Name): JAYNE RANEE ANTOLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69175 RAMON RD BLDG A
CATHEDRAL CITY CA
92234-3344
US

IV. Provider business mailing address

36289 CHERRYWOOD DR
YUCAIPA CA
92399-5730
US

V. Phone/Fax

Practice location:
  • Phone: 760-321-6776
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95053544
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95006784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: