Healthcare Provider Details

I. General information

NPI: 1629759980
Provider Name (Legal Business Name): LISA MARIE RENNER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE SUKACKAS

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 07/28/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 FLEISCHMANN WAY
CARSON CITY NV
89703-2995
US

IV. Provider business mailing address

2350 MERRIT DR
CARSON CITY NV
89701-5693
US

V. Phone/Fax

Practice location:
  • Phone: 775-445-5632
  • Fax:
Mailing address:
  • Phone: 480-779-9005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number869971
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: