Healthcare Provider Details

I. General information

NPI: 1760352934
Provider Name (Legal Business Name): AMANDA MARIE YSLAVA MRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11799 SEBASTIAN WAY STE 103
RANCHO CUCAMONGA CA
91730-0708
US

IV. Provider business mailing address

18645 KEYES DR
BANNING CA
92220-9604
US

V. Phone/Fax

Practice location:
  • Phone: 800-465-3202
  • Fax:
Mailing address:
  • Phone: 909-554-9738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: