Provider Demographics
NPI:1609890300
Name:RENICK, JANICE M (ANP)
Entity Type:Individual
Prefix:MS
First Name:JANICE
Middle Name:M
Last Name:RENICK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7603 FOREST AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4942
Mailing Address - Country:US
Mailing Address - Phone:804-282-8005
Mailing Address - Fax:804-288-0269
Practice Address - Street 1:7603 FOREST AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4942
Practice Address - Country:US
Practice Address - Phone:804-282-8005
Practice Address - Fax:804-288-0269
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024102491363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1609890300Medicaid
P00677461Medicare PIN
VA018547C28Medicare PIN