Healthcare Provider Details

I. General information

NPI: 1376730614
Provider Name (Legal Business Name): GLENDA RAE LYTLE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15400 FOOTHILL BLVD
SAN LEANDRO CA
94578
US

IV. Provider business mailing address

1411 E 31ST ST
OAKLAND CA
94602
US

V. Phone/Fax

Practice location:
  • Phone: 510-895-4343
  • Fax: 510-895-4333
Mailing address:
  • Phone: 510-437-6471
  • Fax: 510-437-4613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN191271
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: