Basic Information
| Provider Information | |||||||||
| NPI: | 1366595886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNYDER | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | F.N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SNYDER | ||||||||
| OtherFirstName: | RUSTEE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | F.N.P. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17095 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923456004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602416666 | ||||||||
| FaxNumber: | 7602474368 | ||||||||
| Practice Location | |||||||||
| Address1: | 19333 BEAR VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602416666 | ||||||||
| FaxNumber: | 7602474368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 10/10/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 3670 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.