Provider Demographics
NPI:1245218932
Name:RENICK, BEVERLY GAYLE (FNP PA-C)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:GAYLE
Last Name:RENICK
Suffix:
Gender:F
Credentials:FNP PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:779 PORT WALK PLACE
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94065
Mailing Address - Country:US
Mailing Address - Phone:650-622-9943
Mailing Address - Fax:
Practice Address - Street 1:450 STANYAN
Practice Address - Street 2:2ND FLOOR USF STUDENT MEDICAL CLINIC ST MARYS MEDICAL C
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1079
Practice Address - Country:US
Practice Address - Phone:415-750-4980
Practice Address - Fax:415-750-8155
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13272363A00000X
CA272543363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA132720OtherPPIN
CA0PA132720OtherPPIN