Provider Demographics
NPI:1437141579
Name:WALDEN, RENEE LYNN (OD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:LYNN
Last Name:WALDEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:LYNN
Other - Last Name:FEIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:9188 GOLF VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-9268
Mailing Address - Country:US
Mailing Address - Phone:715-358-1978
Mailing Address - Fax:
Practice Address - Street 1:8201 MISH KO SWEN DR
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-8631
Practice Address - Country:US
Practice Address - Phone:715-478-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1482DT152W00000X
WI3068-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38643900Medicaid
V81894Medicare UPIN