Provider Demographics
NPI: | 1790235117 |
---|---|
Name: | MAWHINNEY, KATHERYN (RN, CRNA) |
Entity Type: | Individual |
Prefix: | |
First Name: | KATHERYN |
Middle Name: | |
Last Name: | MAWHINNEY |
Suffix: | |
Gender: | F |
Credentials: | RN, CRNA |
Other - Prefix: | |
Other - First Name: | KATHERYN |
Other - Middle Name: | |
Other - Last Name: | TIPTON |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | RN, CRNA |
Mailing Address - Street 1: | 807 PROMONTORY DR W |
Mailing Address - Street 2: | |
Mailing Address - City: | NEWPORT BEACH |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92660-7361 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 714-357-7529 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 400 N PEPPER AVE |
Practice Address - Street 2: | |
Practice Address - City: | COLTON |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92324-1801 |
Practice Address - Country: | US |
Practice Address - Phone: | 909-580-2440 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2016-10-10 |
Last Update Date: | 2023-04-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 7122 | 367500000X |
CA | 95000754 | 367500000X |
CA | 100531 | 282N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | |
No | 282N00000X | Hospitals | General Acute Care Hospital |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 1063823953 | Other | NPI |