Provider Demographics
NPI:1073112637
Name:RENNER, CAROLINE SAMANTHA (MSN)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:SAMANTHA
Last Name:RENNER
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 POWELL AVE SW
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2908
Mailing Address - Country:US
Mailing Address - Phone:425-277-1311
Mailing Address - Fax:
Practice Address - Street 1:16345 NE 87TH ST # B6
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3503
Practice Address - Country:US
Practice Address - Phone:425-882-1697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI61102620133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered