Provider Demographics
NPI:1265975171
Name:RENSLOW, TERI (THERESA) M
Entity type:Individual
Prefix:
First Name:TERI (THERESA)
Middle Name:M
Last Name:RENSLOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:RENSLOW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:316 NICOLE LN
Mailing Address - Street 2:#5D
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-3452
Mailing Address - Country:US
Mailing Address - Phone:715-821-0992
Mailing Address - Fax:
Practice Address - Street 1:316 NICOLE LN
Practice Address - Street 2:#5D
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-3452
Practice Address - Country:US
Practice Address - Phone:715-821-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-25
Last Update Date:2016-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIR5248136091205172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver