MEDICARE: EXTENSIVE HEALTHCARE PROVIDERS A NURSING PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1952269870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENSIVE HEALTHCARE PROVIDERS A NURSING PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	1634 PLANTATION WAY
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92019-3603
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1634 PLANTATION WAY
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92019-3603
Country	:	US
Telephone Number	:	619-395-8558
Fax Number	:

Authorized Official
Title or Position	:	CEO & PRESIDENT
Name	:	MAE PET FETHERLIN
Credential	:
Telephone Number	:	619-395-8558

Provider Enumeration Date	:	01/10/2026
Last Update Date	:	01/10/2026

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