Provider Demographics
NPI:1487026050
Name:BARTLETT, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BARTLETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 S SULTANA AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-8727
Mailing Address - Country:US
Mailing Address - Phone:909-438-8668
Mailing Address - Fax:
Practice Address - Street 1:2820 S SULTANA AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8727
Practice Address - Country:US
Practice Address - Phone:909-438-8668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002591282N00000X, 314000000X, 364SE0003X, 364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency
No282N00000XHospitalsGeneral Acute Care Hospital
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care