Provider Demographics
NPI:1750011540
Name:RENNER, BAILEY RAE
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:RAE
Last Name:RENNER
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 1:211 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:KS
Mailing Address - Zip Code:67748-1218
Mailing Address - Country:US
Mailing Address - Phone:785-672-3211
Mailing Address - Fax:
Practice Address - Street 1:211 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:OAKLEY
Practice Address - State:KS
Practice Address - Zip Code:67748-1218
Practice Address - Country:US
Practice Address - Phone:785-672-3211
Practice Address - Fax:785-672-8184
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS15-02705363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program