Healthcare Provider Details

I. General information

NPI: 1912098864
Provider Name (Legal Business Name): RENOTTA GAIL STAINBROOK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR MAIL ROUTING: 112A
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

3312 40TH ST S
SAINT CLOUD MN
56301-9340
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-6480
  • Fax:
Mailing address:
  • Phone: 320-252-3125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number083577-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: