Provider Demographics
NPI:1598637290
Name:RENISH, ANSA
Entity type:Individual
Prefix:
First Name:ANSA
Middle Name:
Last Name:RENISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 CASCADE ST APT A
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-3310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 REPUBLIC PKWY STE 100
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6920
Practice Address - Country:US
Practice Address - Phone:972-613-4715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222012247000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information