Provider Demographics
NPI:1104247402
Name:FENNELL, LILLIE RUTH (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:LILLIE
Middle Name:RUTH
Last Name:FENNELL
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1554 N IDYLLWILD AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-3159
Mailing Address - Country:US
Mailing Address - Phone:909-820-6241
Mailing Address - Fax:
Practice Address - Street 1:1554 N IDYLLWILD AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-3159
Practice Address - Country:US
Practice Address - Phone:909-820-6241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-04
Last Update Date:2014-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA462743163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse