Provider Demographics
NPI:1770936635
Name:PETILLO, GLENN
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:PETILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37802 FISCHER RD
Mailing Address - Street 2:
Mailing Address - City:ANZA
Mailing Address - State:CA
Mailing Address - Zip Code:92539-9203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37802 FISCHER RD
Practice Address - Street 2:
Practice Address - City:ANZA
Practice Address - State:CA
Practice Address - Zip Code:92539-9203
Practice Address - Country:US
Practice Address - Phone:951-551-3204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00903914376K00000X
CA00270053374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00270053OtherCALIFORNIA DEPARTMENT OF PUBLIC HEALTH HOME HEALTH AIDE
CA00903914OtherCALIFORNIA DEPARTMENT OF PUBLIC HEALTH CERTIFIED NURSING ASSISTANT