Provider Demographics
NPI:1619618105
Name:RENO, DEREK SCOTT (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:SCOTT
Last Name:RENO
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E UNION ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-3246
Mailing Address - Country:US
Mailing Address - Phone:662-725-2749
Mailing Address - Fax:662-725-2741
Practice Address - Street 1:1400 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3246
Practice Address - Country:US
Practice Address - Phone:662-822-6046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905331363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily