Provider Demographics
NPI:1750451134
Name:HANEVOLD, RENEE L (APN, CNM)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:L
Last Name:HANEVOLD
Suffix:
Gender:F
Credentials:APN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 NEEDLE CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-6953
Mailing Address - Country:US
Mailing Address - Phone:916-512-5522
Mailing Address - Fax:916-872-4790
Practice Address - Street 1:224 NEEDLE CT
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-6953
Practice Address - Country:US
Practice Address - Phone:916-512-5522
Practice Address - Fax:916-872-4790
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW 1927367A00000X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1750451134Medicaid
CAQHOther11225132
CAQHOther11225132