Healthcare Provider Details

I. General information

NPI: 1750678231
Provider Name (Legal Business Name): CAITLIN RENN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 SO 30TH STREET SUITE 103
OMAHA NE
68107-1656
US

IV. Provider business mailing address

7720 N FRESNO ST STE 104
FRESNO CA
93720-2407
US

V. Phone/Fax

Practice location:
  • Phone: 402-734-4110
  • Fax: 402-734-3990
Mailing address:
  • Phone: 559-438-2300
  • Fax: 559-438-1531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6619
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC169909
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: