Provider Demographics
NPI:1619352168
Name:MAMMOO, RENA
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:MAMMOO
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 1:16801 CHILLICOTHE RD
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-4618
Mailing Address - Country:US
Mailing Address - Phone:440-543-7475
Mailing Address - Fax:
Practice Address - Street 1:16801 CHILLICOTHE RD
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44023-4618
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013051363L00000X
OH0030086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner