Provider Demographics
NPI:1255945200
Name:RENDLE, MICHAEL JAY (NP-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAY
Last Name:RENDLE
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12032 CHAMPLAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7713
Mailing Address - Country:US
Mailing Address - Phone:951-203-7865
Mailing Address - Fax:
Practice Address - Street 1:12032 CHAMPLAIN ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-7713
Practice Address - Country:US
Practice Address - Phone:951-203-7865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-06
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1070301363LF0000X
CA95014922363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily