Provider Demographics
NPI:1912489980
Name:GAULT, RENEE (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:
Last Name:GAULT
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 HOSPITAL WAY STE 477
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2744
Mailing Address - Country:US
Mailing Address - Phone:208-233-7832
Mailing Address - Fax:208-233-7835
Practice Address - Street 1:444 HOSPITAL WAY STE 477
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2744
Practice Address - Country:US
Practice Address - Phone:208-233-7832
Practice Address - Fax:208-233-7835
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID59582363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health