Provider Demographics
NPI:1730100918
Name:IDEL, RENEE D (ANP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:D
Last Name:IDEL
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 1:4921 PARKVIEW PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1032
Mailing Address - Country:US
Mailing Address - Phone:314-454-8134
Mailing Address - Fax:314-454-8180
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-454-8134
Practice Address - Fax:314-454-8180
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA517511363LA2200X
MO117226363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP99237Medicare UPIN