Basic Information
| Provider Information | |||||||||
| NPI: | 1245668326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLORY | ||||||||
| FirstName: | TRENA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAWZA | ||||||||
| OtherFirstName: | TRENA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6170 W LAKE MEAD BLVD | ||||||||
| Address2: | #461 PMB 2335 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891082661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022174808 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8424 E SHEA BLVD | ||||||||
| Address2: | #101 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804786620 | ||||||||
| FaxNumber: | 4603043444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2013 | ||||||||
| LastUpdateDate: | 10/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CRNA0980 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.