Provider Demographics
NPI:1407553498
Name:DE VERA, ELLEN MAE ALCANTARA (CRNA)
Entity Type:Individual
Prefix:
First Name:ELLEN MAE
Middle Name:ALCANTARA
Last Name:DE VERA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12842 PALM ST PH 1
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-6427
Mailing Address - Country:US
Mailing Address - Phone:858-519-4161
Mailing Address - Fax:
Practice Address - Street 1:4500 MORNING DR STE 102
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-7276
Practice Address - Country:US
Practice Address - Phone:661-437-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA143616367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered