Healthcare Provider Details

I. General information

NPI: 1417649013
Provider Name (Legal Business Name): ETHLENE EVETTE DADE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 OCEANGATE STE 100
LONG BEACH CA
90802-4317
US

IV. Provider business mailing address

14390 DALTON CT
VICTORVILLE CA
92394-3212
US

V. Phone/Fax

Practice location:
  • Phone: 760-936-7118
  • Fax:
Mailing address:
  • Phone: 323-973-3647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1208802
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95025043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: