Provider Demographics
NPI:1194821355
Name:SMALL, RENEE R (NP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:R
Last Name:SMALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:R
Other - Last Name:KRAFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5501
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58506-5501
Mailing Address - Country:US
Mailing Address - Phone:701-323-6000
Mailing Address - Fax:701-323-5709
Practice Address - Street 1:222 N 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4436
Practice Address - Country:US
Practice Address - Phone:701-323-6000
Practice Address - Fax:701-323-5883
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR23515363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19711Medicaid
ND19711Medicaid
ND22232Medicare PIN