Healthcare Provider Details

I. General information

NPI: 1891182002
Provider Name (Legal Business Name): SHETERAH BURNETT-WRENN LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2015
Last Update Date: 04/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3686 PACIFIC AVE
RIVERSIDE CA
92509-1948
US

IV. Provider business mailing address

3686 PACIFIC AVE
RIVERSIDE CA
92509-1948
US

V. Phone/Fax

Practice location:
  • Phone: 951-801-2913
  • Fax:
Mailing address:
  • Phone: 951-801-2913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number279099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: