Provider Demographics
NPI:1881631786
Name:RENTERIA, SUSAN KAY (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:RENTERIA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10885 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1272
Mailing Address - Country:US
Mailing Address - Phone:805-647-7704
Mailing Address - Fax:805-647-3002
Practice Address - Street 1:10885 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1272
Practice Address - Country:US
Practice Address - Phone:805-647-7704
Practice Address - Fax:805-647-7084
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN350758/NP10828363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN350758Medicaid
CAP20768Medicare UPIN
CAWNP10828BMedicare PIN
CARN350758Medicaid