Provider Demographics
NPI:1952035453
Name:RENNER-KEVKHISHVILI, JENNIFER R (APNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:RENNER-KEVKHISHVILI
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RENE
Other - Last Name:RENNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-0231
Mailing Address - Fax:414-805-6808
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-0231
Practice Address - Fax:414-805-6808
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12163363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1952035453Medicaid