Provider Demographics
NPI:1114752805
Name:PORNELOS, SUZETTE L (RN)
Entity type:Individual
Prefix:MISS
First Name:SUZETTE
Middle Name:L
Last Name:PORNELOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13393 MARIPOSA RD SPC 213
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5328
Mailing Address - Country:US
Mailing Address - Phone:760-985-3259
Mailing Address - Fax:
Practice Address - Street 1:2910 INLAND EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4896
Practice Address - Country:US
Practice Address - Phone:909-522-4093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA786944163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice