Healthcare Provider Details

I. General information

NPI: 1497126197
Provider Name (Legal Business Name): SETH ESLY CHELLIAH MSN, PHN, RN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 TENNESSEE ST STE C
REDLANDS CA
92373-8161
US

IV. Provider business mailing address

26470 ANTONIO CIR
LOMA LINDA CA
92354-6758
US

V. Phone/Fax

Practice location:
  • Phone: 909-475-7571
  • Fax:
Mailing address:
  • Phone: 909-809-2139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95068057
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95012110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: