Glenn Petillo
Individual provider Active NPI Nurse's Aide · Anza, CA
NPI 1770936635 · NPPES record last updated Jul 15, 2016
Key facts
- NPI
- 1770936635
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Nurse's Aide 376K00000X
- License
- 00903914 (CA)
- Practice address
- 37802 Fischer Rd
Anza, CA 92539-9203 - Phone
- (951) 551-3204
- NPI assigned
- Jul 15, 2016
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 00270053 | CA | MD | Home Health Aide |
| 00903914 | CA | MD | Nurse's Aide |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nurse's Aide | 376K00000X | 00903914 | CA | Yes |
| Home Health Aide | 374U00000X | 00270053 | CA |
Addresses
Primary practice location
37802 Fischer Rd
Anza, CA 92539-9203
Mailing address
37802 Fischer Rd
Anza, CA 92539-9203
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00270053 | Other | CA | CALIFORNIA DEPARTMENT OF PUBLIC HEALTH HOME HEALTH AIDE |
| 00903914 | Other | CA | CALIFORNIA DEPARTMENT OF PUBLIC HEALTH CERTIFIED NURSING ASSISTANT |
Other providers in Anza, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 15, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.