Provider Demographics
NPI:1598938961
Name:RENNER, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:RENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2272 N PLEASANTS HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:ST. MARYS
Mailing Address - State:WV
Mailing Address - Zip Code:26170-0021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2272 N PLEASANTS HIGHWAY
Practice Address - Street 2:
Practice Address - City:ST. MARYS
Practice Address - State:WV
Practice Address - Zip Code:26170-0021
Practice Address - Country:US
Practice Address - Phone:304-684-2215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV52707163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006857Medicaid