Provider Demographics
NPI:1760530521
Name:RENNICK, RENEE M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:M
Last Name:RENNICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6826
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-0921
Mailing Address - Country:US
Mailing Address - Phone:304-242-7106
Mailing Address - Fax:304-242-7108
Practice Address - Street 1:426 8TH ST STE 105
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1451
Practice Address - Country:US
Practice Address - Phone:740-633-4765
Practice Address - Fax:740-633-6450
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002445363AM0700X, 363AS0400X
WV718363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1760530521Medicaid
OH0131865Medicaid
OHREPA37001Medicare PIN