Provider Demographics
NPI:1093132409
Name:FARAG, RENEE NICOLE (CNA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:NICOLE
Last Name:FARAG
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 SADDLEBACK LANE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602
Mailing Address - Country:US
Mailing Address - Phone:870-310-7406
Mailing Address - Fax:
Practice Address - Street 1:171 COW LANE
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:AR
Practice Address - Zip Code:71749
Practice Address - Country:US
Practice Address - Phone:870-310-7406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR050344200311E171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor