Provider Demographics
NPI:1245668326
Name:MALLORY, TRENA MARIE (CRNA)
Entity type:Individual
Prefix:MS
First Name:TRENA
Middle Name:MARIE
Last Name:MALLORY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:TRENA
Other - Middle Name:MARIE
Other - Last Name:RAWZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6170 W LAKE MEAD BLVD
Mailing Address - Street 2:#461 PMB 2335
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-2661
Mailing Address - Country:US
Mailing Address - Phone:702-217-4808
Mailing Address - Fax:
Practice Address - Street 1:8424 E SHEA BLVD
Practice Address - Street 2:#101
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6662
Practice Address - Country:US
Practice Address - Phone:480-478-6620
Practice Address - Fax:460-304-3444
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0980367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered