Healthcare Provider Details

I. General information

NPI: 1063550911
Provider Name (Legal Business Name): LYNNETT L RENNER RD, LDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WHITLEY ST
LONDON KY
40741
US

IV. Provider business mailing address

525 WHITLEY ST
LONDON KY
40741-2626
US

V. Phone/Fax

Practice location:
  • Phone: 606-864-5187
  • Fax: 606-864-8295
Mailing address:
  • Phone: 606-864-5187
  • Fax: 606-864-8295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0625
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: