Provider Demographics
NPI:1447695275
Name:CUNNINGHAM, CAROLYN (CRNA)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 S OLA VIS
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4342
Mailing Address - Country:US
Mailing Address - Phone:949-366-5476
Mailing Address - Fax:
Practice Address - Street 1:1702 S OLA VIS
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4342
Practice Address - Country:US
Practice Address - Phone:949-366-5476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA181994367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered