Provider Demographics
NPI:1215011671
Name:KENWORTHY, RENEE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:
Last Name:KENWORTHY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WHITE PINE WAY
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36869-7983
Mailing Address - Country:US
Mailing Address - Phone:334-214-5332
Mailing Address - Fax:
Practice Address - Street 1:MACH/RPC
Practice Address - Street 2:MARTIN LOOP BLDG 9224
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:706-544-3919
Practice Address - Fax:706-544-2790
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN072185164W00000X
WALP00053625164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse