Provider Demographics
NPI:1922612159
Name:GAVIN, RENIA NICOLE
Entity Type:Individual
Prefix:
First Name:RENIA
Middle Name:NICOLE
Last Name:GAVIN
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 1:537 E JOHN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-4156
Mailing Address - Country:US
Mailing Address - Phone:937-319-3959
Mailing Address - Fax:
Practice Address - Street 1:537 E JOHN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-4156
Practice Address - Country:US
Practice Address - Phone:937-319-3959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0001864175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty