Healthcare Provider Details

I. General information

NPI: 1831913821
Provider Name (Legal Business Name): SHANNON LACEY YERTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

658 E BRIER DR
SAN BERNARDINO CA
92408-2880
US

IV. Provider business mailing address

658 E BRIER DR STE 250
SAN BERNARDINO CA
92408-2875
US

V. Phone/Fax

Practice location:
  • Phone: 909-501-0761
  • Fax:
Mailing address:
  • Phone: 909-501-0761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: