Provider Demographics
NPI:1154055085
Name:STAVINOHA, KERRY LYNN
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LYNN
Last Name:STAVINOHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 DENTRO DE LOMAS
Mailing Address - Street 2:
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-6811
Mailing Address - Country:US
Mailing Address - Phone:760-390-5485
Mailing Address - Fax:
Practice Address - Street 1:1409 DENTRO DE LOMAS
Practice Address - Street 2:
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-6811
Practice Address - Country:US
Practice Address - Phone:760-390-5485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6203369163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse