Provider Demographics
NPI:1487860383
Name:RENNICK, TERESA ANN (PMHNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN
Last Name:RENNICK
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3314 VANDENBERG RD
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-3730
Mailing Address - Country:US
Mailing Address - Phone:541-882-7291
Mailing Address - Fax:541-883-4213
Practice Address - Street 1:3314 VANDENBERG RD
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-3730
Practice Address - Country:US
Practice Address - Phone:541-882-7291
Practice Address - Fax:541-883-4213
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOOO32868363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100315Medicaid
ORS35658Medicare UPIN
OR104181Medicare ID - Type UnspecifiedOREGON MEDICARE NUMBER