Provider Demographics
NPI:1760630131
Name:RENNER, MANDIE LEIGH (CCNS)
Entity Type:Individual
Prefix:MRS
First Name:MANDIE
Middle Name:LEIGH
Last Name:RENNER
Suffix:
Gender:F
Credentials:CCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1120 S UTICA AVE STE 2123
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4012
Mailing Address - Country:US
Mailing Address - Phone:189-579-5402
Mailing Address - Fax:918-579-5404
Practice Address - Street 1:1120 S UTICA AVE STE 2123
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104
Practice Address - Country:US
Practice Address - Phone:918-579-5402
Practice Address - Fax:918-579-5404
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK81378364SN0000X
OK80137363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal