Provider Demographics
NPI:1922516632
Name:RENEAU, YANICK MAXENA
Entity Type:Individual
Prefix:
First Name:YANICK
Middle Name:MAXENA
Last Name:RENEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2756 NW 1ST CT
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-2501
Mailing Address - Country:US
Mailing Address - Phone:954-627-2513
Mailing Address - Fax:
Practice Address - Street 1:10650 W STATE ROAD 84 STE 206
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-4235
Practice Address - Country:US
Practice Address - Phone:954-634-3636
Practice Address - Fax:954-634-3637
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022917800Medicaid