1558955849 NPI number — MISS KATHLEEN R RENNER A.P.R.N.

Table of content: MISS KATHLEEN R RENNER A.P.R.N. (NPI 1558955849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558955849 NPI number — MISS KATHLEEN R RENNER A.P.R.N.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RENNER
Provider First Name:
KATHLEEN
Provider Middle Name:
R
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
A.P.R.N.
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:
1558955849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4147 SOUTHPOINT DR EAST
Provider Second Line Business Mailing Address:
OPTIONAL
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-332-6774
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4147 SOUTHPOINT DR EAST
Provider Second Line Business Practice Location Address:
OPTIONAL
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-332-6774
Provider Business Practice Location Address Fax Number:
904-661-0028
Provider Enumeration Date:
02/26/2021

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: 208200000X , with the licence number:  APRN11008064 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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