Healthcare Provider Details

I. General information

NPI: 1083008254
Provider Name (Legal Business Name): MARETHA TYCE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

IV. Provider business mailing address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-7320
  • Fax:
Mailing address:
  • Phone: 909-881-7320
  • Fax: 909-881-7329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95002142
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: