Provider Demographics
NPI:1245448539
Name:GAGNON, RENONNA KAY (LMT)
Entity type:Individual
Prefix:MRS
First Name:RENONNA
Middle Name:KAY
Last Name:GAGNON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 TRAM BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-7739
Mailing Address - Country:US
Mailing Address - Phone:843-873-9038
Mailing Address - Fax:
Practice Address - Street 1:517 TRAM BLVD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7739
Practice Address - Country:US
Practice Address - Phone:843-873-9038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4541171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor