Healthcare Provider Details

I. General information

NPI: 1629141486
Provider Name (Legal Business Name): RENEE M JOHANNENSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENEE J NOVELLO MD

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 03/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

IV. Provider business mailing address

289 COUNTY RD
WINDSOR VT
05089-9000
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5000
  • Fax:
Mailing address:
  • Phone: 802-674-7300
  • Fax: 802-674-7314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number13120
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number263512
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number042-0011195
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: