Provider Demographics
NPI:1043494503
Name:RENNER, MELISA KAYE (APRN, MSN, FNP-C)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:KAYE
Last Name:RENNER
Suffix:
Gender:F
Credentials:APRN, MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6326 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1518
Mailing Address - Country:US
Mailing Address - Phone:260-515-3275
Mailing Address - Fax:888-803-6843
Practice Address - Street 1:6326 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1518
Practice Address - Country:US
Practice Address - Phone:260-515-3275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010644A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300047110Medicaid