Provider Demographics
NPI:1376730614
Name:LYTLE, GLENDA RAE (RN)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:RAE
Last Name:LYTLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602
Mailing Address - Country:US
Mailing Address - Phone:510-437-6471
Mailing Address - Fax:510-437-4613
Practice Address - Street 1:15400 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578
Practice Address - Country:US
Practice Address - Phone:510-895-4343
Practice Address - Fax:510-895-4333
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN191271163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse