Healthcare Provider Details

I. General information

NPI: 1871738401
Provider Name (Legal Business Name): DIEDRE ANN RENSTROM NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

1405 LONGWOOD DR
NORFOLK VA
23508-1722
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7456
  • Fax: 757-668-9255
Mailing address:
  • Phone: 757-588-4814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number0024167924
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: