Healthcare Provider Details

I. General information

NPI: 1942199526
Provider Name (Legal Business Name): TYRONE JERMAINE WALCOTT NP
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10801 6TH ST STE 120
RANCHO CUCAMONGA CA
91730-5987
US

IV. Provider business mailing address

4195 CHINO HILLS PKWY
CHINO HILLS CA
91709-2618
US

V. Phone/Fax

Practice location:
  • Phone: 800-440-4347
  • Fax:
Mailing address:
  • Phone: 910-323-1718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5022573
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5022573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: