Basic Information
| Provider Information | |||||||||
| NPI: | 1801510201 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARIANO | ||||||||
| FirstName: | SHARLETTE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3805 BUR OAK RD | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924079081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106128809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095801000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2022 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95020940 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 95020940 | 05 | CA | MEDICAID |