Provider Demographics
NPI:1477530814
Name:WILLER, RENEE L (APRN)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:L
Last Name:WILLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:L
Other - Last Name:BUCHANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:4581 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:HOUSE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63051-1374
Mailing Address - Country:US
Mailing Address - Phone:636-671-9980
Mailing Address - Fax:636-671-9981
Practice Address - Street 1:4581 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:HOUSE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:63051-1374
Practice Address - Country:US
Practice Address - Phone:636-671-9980
Practice Address - Fax:636-671-9981
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO138512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO138513OtherLICENSE
MO1477530814Medicaid
MO1477530814Medicaid
MOMA5214001Medicare Oscar/Certification
MOQ61694Medicare UPIN
MO1477530814Medicaid
MO595379314Medicaid
MO263903Medicare Oscar/Certification