Provider Demographics
NPI:1629080056
Name:STENNIS, CORENE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CORENE
Middle Name:
Last Name:STENNIS
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 1:1340 N MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-2504
Mailing Address - Country:US
Mailing Address - Phone:909-824-2611
Mailing Address - Fax:909-824-7701
Practice Address - Street 1:11332 MOUNTAIN VIEW AVE STE A
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3854
Practice Address - Country:US
Practice Address - Phone:909-796-3707
Practice Address - Fax:909-796-3709
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA57367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20422ZMedicare ID - Type Unspecified