Provider Demographics
NPI:1508179417
Name:WIDNER REN, VANESSA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:LYNN
Last Name:WIDNER REN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VANESSA
Other - Middle Name:LYNN
Other - Last Name:WIDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5100 NW WAUKOMIS DR STE A
Mailing Address - Street 2:
Mailing Address - City:NORTHMOOR
Mailing Address - State:MO
Mailing Address - Zip Code:64151-3516
Mailing Address - Country:US
Mailing Address - Phone:913-980-4697
Mailing Address - Fax:844-380-1190
Practice Address - Street 1:5100 NW WAUKOMIS DR STE A
Practice Address - Street 2:
Practice Address - City:NORTHMOOR
Practice Address - State:MO
Practice Address - Zip Code:64151-3516
Practice Address - Country:US
Practice Address - Phone:913-980-4697
Practice Address - Fax:844-380-1190
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013037136207QA0401X, 207QA0505X, 207QH0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty