Provider Demographics
NPI:1598359002
Name:WELLS, SHARDAE GWENDOLYN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHARDAE
Middle Name:GWENDOLYN
Last Name:WELLS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13075 PALISADE PL
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-6428
Mailing Address - Country:US
Mailing Address - Phone:951-902-3842
Mailing Address - Fax:
Practice Address - Street 1:1800 WESTERN AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1353
Practice Address - Country:US
Practice Address - Phone:909-474-9952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016553363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily