Provider Demographics
NPI:1255409546
Name:RENN, TRACY A (FNP-BC, ACNS-BC APNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:RENN
Suffix:
Gender:F
Credentials:FNP-BC, ACNS-BC APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:893 WILLOW RIVER DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-6944
Mailing Address - Country:US
Mailing Address - Phone:715-246-7895
Mailing Address - Fax:
Practice Address - Street 1:246 TIERNEY DR
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-2515
Practice Address - Country:US
Practice Address - Phone:715-246-2521
Practice Address - Fax:715-246-7977
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2008-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2006008321-05364SA2200X
WI2077005215-22363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36024100Medicaid
WI36024100Medicaid
WI000456060Medicare ID - Type Unspecified