Healthcare Provider Details

I. General information

NPI: 1598547408
Provider Name (Legal Business Name): AMANDA S RENNIE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 S LIBERTY DR
BLOOMINGTON IN
47403-5167
US

IV. Provider business mailing address

1520 S LIBERTY DR
BLOOMINGTON IN
47403-5167
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4300
  • Fax:
Mailing address:
  • Phone: 812-676-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28250897A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71014562A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number71014562A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: