Provider Demographics
NPI:1598363913
Name:RENFROE, JOAN MAYRE (LVN, IP, DSD)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:MAYRE
Last Name:RENFROE
Suffix:
Gender:F
Credentials:LVN, IP, DSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 SAINT MICHELE
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5737
Mailing Address - Country:US
Mailing Address - Phone:813-952-7750
Mailing Address - Fax:
Practice Address - Street 1:699 WINNERS CIR
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92582-2741
Practice Address - Country:US
Practice Address - Phone:951-487-3815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5199749164W00000X
CA708453164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse