Provider Demographics
NPI:1417493420
Name:SIMON, GLADYS NYAWIRA (LVN)
Entity Type:Individual
Prefix:MRS
First Name:GLADYS
Middle Name:NYAWIRA
Last Name:SIMON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 S ARCHIBALD AVE
Mailing Address - Street 2:APT I
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7944
Mailing Address - Country:US
Mailing Address - Phone:909-657-3291
Mailing Address - Fax:909-657-3291
Practice Address - Street 1:3303 S ARCHIBALD AVE
Practice Address - Street 2:APT I
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7944
Practice Address - Country:US
Practice Address - Phone:909-657-3291
Practice Address - Fax:909-657-3291
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN212826164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse