Provider Demographics
NPI:1417547225
Name:MAMO-RENNERT, KIMBERLY LAUREN
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LAUREN
Last Name:MAMO-RENNERT
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:LAUREN
Other - Last Name:MAMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:175 N GROESBECK HWY
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-1562
Mailing Address - Country:US
Mailing Address - Phone:586-914-2160
Mailing Address - Fax:
Practice Address - Street 1:175 N GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-1562
Practice Address - Country:US
Practice Address - Phone:586-914-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator