Provider Demographics
NPI:1801510201
Name:MARIANO, SHARLETTE (FNP)
Entity type:Individual
Prefix:
First Name:SHARLETTE
Middle Name:
Last Name:MARIANO
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 1:3805 BUR OAK RD
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-9081
Mailing Address - Country:US
Mailing Address - Phone:310-612-8809
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020940363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95020940Medicaid