Provider Demographics
NPI:1346241262
Name:EDWARDS, RENEE (FNP)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 SW 4TH ST
Mailing Address - Street 2:STE 200
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4724
Mailing Address - Country:US
Mailing Address - Phone:541-624-2040
Mailing Address - Fax:503-200-2258
Practice Address - Street 1:656 NW MIRADOR PL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4698
Practice Address - Country:US
Practice Address - Phone:541-624-2040
Practice Address - Fax:503-200-2258
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450130NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269505Medicaid
OR269505Medicaid
OR131713Medicare ID - Type Unspecified