Provider Demographics
NPI:1811098486
Name:KOEMPTGEN, RENEE DIANE (CNS)
Entity type:Individual
Prefix:MS
First Name:RENEE
Middle Name:DIANE
Last Name:KOEMPTGEN
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 HAWES AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-6233
Mailing Address - Country:US
Mailing Address - Phone:651-330-6313
Mailing Address - Fax:
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1092266364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q03411Medicare UPIN