Provider Demographics
NPI:1073644506
Name:RENNA, PAULA CHRISTINE
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:CHRISTINE
Last Name:RENNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 VIRGIL ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2637
Mailing Address - Country:US
Mailing Address - Phone:636-272-1059
Mailing Address - Fax:636-980-1946
Practice Address - Street 1:110 VIRGIL ST
Practice Address - Street 2:FT ZUMWALT R-II
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2637
Practice Address - Country:US
Practice Address - Phone:636-272-1059
Practice Address - Fax:636-980-1946
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113028235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO463499715Medicaid