Basic Information
Provider Information | |||||||||
NPI: | 1306104625 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SWINNEY | ||||||||
FirstName: | JEANELLE | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SWINNEY | ||||||||
OtherFirstName: | JEANELLE | ||||||||
OtherMiddleName: | NICOLE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 15095 AMARGOSA RD | ||||||||
Address2: | SUITE201 | ||||||||
City: | VICTORVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 923941879 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602454695 | ||||||||
FaxNumber: | 7605134676 | ||||||||
Practice Location | |||||||||
Address1: | 15095 AMARGOSA RD | ||||||||
Address2: | SUITE201 | ||||||||
City: | VICTORVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 923941879 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602454695 | ||||||||
FaxNumber: | 7605134676 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2012 | ||||||||
LastUpdateDate: | 08/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X |   |   | Y |   | Other Service Providers | Community Health Worker |   |
No ID Information.