Provider Demographics
NPI:1245332865
Name:REISNER, DENISE MCKENNA (CPNP)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:MCKENNA
Last Name:REISNER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:MISS
Other - First Name:DENISE
Other - Middle Name:E
Other - Last Name:MCKENNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8614
Mailing Address - Fax:
Practice Address - Street 1:900 W FARIS RD FL 2
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4255
Practice Address - Country:US
Practice Address - Phone:864-455-8898
Practice Address - Fax:864-241-9237
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2071363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAPPROVEDMedicaid
SCAPPROVEDMedicaid