Provider Demographics
NPI:1255413431
Name:KENNIS, CAROLYN G (CRNA)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:G
Last Name:KENNIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1000
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:10900 WARNER AVE
Practice Address - Street 2:SUITE 101A
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3846
Practice Address - Country:US
Practice Address - Phone:714-698-1270
Practice Address - Fax:714-962-7261
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA000000NA1535367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered