Healthcare Provider Details

I. General information

NPI: 1497704233
Provider Name (Legal Business Name): MARY LEE WHITTEN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501A S BON VIEW AVE
ONTARIO CA
91761-4408
US

IV. Provider business mailing address

12856 HOMERIDGE LN
CHINO HILLS CA
91709-1047
US

V. Phone/Fax

Practice location:
  • Phone: 909-673-9125
  • Fax: 909-673-1676
Mailing address:
  • Phone: 909-673-9125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number334831
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: