Provider Demographics
NPI:1275664765
Name:KINNISON, ARDENELLA (CNM)
Entity Type:Individual
Prefix:MS
First Name:ARDENELLA
Middle Name:
Last Name:KINNISON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3309 RENNER DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3119
Mailing Address - Country:US
Mailing Address - Phone:707-725-6108
Mailing Address - Fax:707-725-9674
Practice Address - Street 1:3309 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3119
Practice Address - Country:US
Practice Address - Phone:707-725-6108
Practice Address - Fax:707-725-9674
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1311367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife