Provider Demographics
NPI:1679187165
Name:WOLVERT, RENEE M
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:M
Last Name:WOLVERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:M
Other - Last Name:WOLVERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RENEE M WOLVERT
Mailing Address - Street 1:102 W GARY ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55808-1737
Mailing Address - Country:US
Mailing Address - Phone:218-626-2286
Mailing Address - Fax:
Practice Address - Street 1:102 W GARY ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55808-1737
Practice Address - Country:US
Practice Address - Phone:218-626-2286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker