Provider Demographics
NPI:1316060320
Name:DENNIS, CHARISSE ANN (LVN)
Entity type:Individual
Prefix:MS
First Name:CHARISSE
Middle Name:ANN
Last Name:DENNIS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 MENTONE BLVD
Mailing Address - Street 2:SP 79
Mailing Address - City:MENTONE
Mailing Address - State:CA
Mailing Address - Zip Code:92359-9703
Mailing Address - Country:US
Mailing Address - Phone:909-794-3469
Mailing Address - Fax:
Practice Address - Street 1:83-912 AVENUE 45
Practice Address - Street 2:SUITE 8
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3338
Practice Address - Country:US
Practice Address - Phone:760-347-0494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 195828164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse