Healthcare Provider Details

I. General information

NPI: 1508179417
Provider Name (Legal Business Name): VANESSA LYNN WIDNER REN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DR. VANESSA LYNN WIDNER

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 NW WAUKOMIS DR STE A
NORTHMOOR MO
64151-3516
US

IV. Provider business mailing address

5100 NW WAUKOMIS DR STE A
NORTHMOOR MO
64151-3516
US

V. Phone/Fax

Practice location:
  • Phone: 913-980-4697
  • Fax: 844-380-1190
Mailing address:
  • Phone: 913-980-4697
  • Fax: 844-380-1190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number2013037136
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number2013037136
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number2013037136
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2013037136
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: