Healthcare Provider Details

I. General information

NPI: 1457485112
Provider Name (Legal Business Name): JENNIFER C RENNINGER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W. OAK STREET
FRACKVILLE PA
17931
US

IV. Provider business mailing address

701 W. OAK STREET
FRACKVILLE PA
17931
US

V. Phone/Fax

Practice location:
  • Phone: 570-874-4100
  • Fax: 570-874-1730
Mailing address:
  • Phone: 570-874-4100
  • Fax: 570-874-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA052923
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: