Provider Demographics
NPI:1639832066
Name:PENROD, KRISTA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:PENROD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-7782
Mailing Address - Country:US
Mailing Address - Phone:951-207-5042
Mailing Address - Fax:
Practice Address - Street 1:6296 RIVER CREST DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0742
Practice Address - Country:US
Practice Address - Phone:951-308-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018918363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily