Provider Demographics
NPI:1265675714
Name:RENFREE, LIESL CORRIN
Entity Type:Individual
Prefix:
First Name:LIESL
Middle Name:CORRIN
Last Name:RENFREE
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 1:10877 CONDUCTOR BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SUTTER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95685-9688
Mailing Address - Country:US
Mailing Address - Phone:209-223-6412
Mailing Address - Fax:209-223-0920
Practice Address - Street 1:10877 CONDUCTOR BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SUTTER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95685-9688
Practice Address - Country:US
Practice Address - Phone:209-223-6412
Practice Address - Fax:209-223-0920
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN747551163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN747551OtherMEDI-CAL