Provider Demographics
NPI:1851370746
Name:ROBBENNOLT, RENA J (CNP)
Entity Type:Individual
Prefix:MRS
First Name:RENA
Middle Name:J
Last Name:ROBBENNOLT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5201
Mailing Address - Fax:605-765-2273
Practice Address - Street 1:608 E GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:SD
Practice Address - Zip Code:57442-1325
Practice Address - Country:US
Practice Address - Phone:605-765-2273
Practice Address - Fax:605-765-2273
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0200363LF0000X
SDCP000200363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6825683Medicaid
SD6825682Medicaid
SD6825682Medicaid
SDS25473Medicare UPIN