Provider Demographics
NPI:1568687275
Name:FENNELL, CHRISTAL LA SHAWN (LVN)
Entity Type:Individual
Prefix:
First Name:CHRISTAL
Middle Name:LA SHAWN
Last Name:FENNELL
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10935 TERRA VISTA PKWY APT 83
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6348
Mailing Address - Country:US
Mailing Address - Phone:909-484-3968
Mailing Address - Fax:
Practice Address - Street 1:10935 TERRA VISTA PKWY APT 83
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6348
Practice Address - Country:US
Practice Address - Phone:909-484-3968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN220919164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse