1750451134 NPI number — RENEE L HANEVOLD APN, CNM

Table of content: RENEE L HANEVOLD APN, CNM (NPI 1750451134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750451134 NPI number — RENEE L HANEVOLD APN, CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANEVOLD
Provider First Name:
RENEE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN, CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750451134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 NEEDLE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95678-6953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-512-5522
Provider Business Mailing Address Fax Number:
916-872-4790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 NEEDLE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95678-6953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-512-5522
Provider Business Practice Location Address Fax Number:
916-872-4790
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  NMW 1927 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LX0001X , with the licence number: NMW 1927 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1750451134 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: CAQH . This is a "11225132" identifier . This identifiers is of the category "OTHER".




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