Healthcare Provider Details

I. General information

NPI: 1558960153
Provider Name (Legal Business Name): RENEA M REANO CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 IRVING BLVD NW APT 508
ALBUQUERQUE NM
87114-3906
US

IV. Provider business mailing address

4701 IRVING BLVD NW APT 508
ALBUQUERQUE NM
87114-3906
US

V. Phone/Fax

Practice location:
  • Phone: 505-916-6162
  • Fax:
Mailing address:
  • Phone: 505-916-6162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number202018145
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number62681
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: