Provider Demographics
NPI:1629141486
Name:JOHANNENSEN, RENEE M (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:M
Last Name:JOHANNENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:J
Other - Last Name:NOVELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:289 COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VT
Mailing Address - Zip Code:05089-9000
Mailing Address - Country:US
Mailing Address - Phone:802-674-7300
Mailing Address - Fax:802-674-7314
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13120207V00000X
NY263512207V00000X
VT042-0011195207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H99022Medicare UPIN