Healthcare Provider Details

I. General information

NPI: 1013142413
Provider Name (Legal Business Name): SHANNON LEE YNFANTE RN FIRST ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2009
Last Update Date: 05/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 SAN BERNARDINO RD
UPLAND CA
91786-4920
US

IV. Provider business mailing address

14006 DAHLIA DR
VICTORVILLE CA
92392-5503
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-2811
  • Fax:
Mailing address:
  • Phone: 951-741-3068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number587878
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: