Healthcare Provider Details

I. General information

NPI: 1275309379
Provider Name (Legal Business Name): REBECCA ANN RENNER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2778 US HIGHWAY 27 S
AVON PARK FL
33825-9755
US

IV. Provider business mailing address

30443 MIMI ST
SEBRING FL
33870-0518
US

V. Phone/Fax

Practice location:
  • Phone: 863-336-5888
  • Fax:
Mailing address:
  • Phone: 863-464-6934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberND7128
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND7128
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: