Healthcare Provider Details

I. General information

NPI: 1215521331
Provider Name (Legal Business Name): MARIA LYN RENNAKER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA LYN CRESS

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3334 DVN LN
DARBY MT
59829-9736
US

IV. Provider business mailing address

3334 DVN LN
DARBY MT
59829-9736
US

V. Phone/Fax

Practice location:
  • Phone: 406-375-4142
  • Fax: 406-375-4143
Mailing address:
  • Phone: 406-381-2713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number91830
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: