Healthcare Provider Details

I. General information

NPI: 1770989253
Provider Name (Legal Business Name): AMY RENNER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 FISHER RD STE 3-1
BERLIN VT
05602-9000
US

IV. Provider business mailing address

130 FISHER RD STE 3-1
BERLIN VT
05602-9000
US

V. Phone/Fax

Practice location:
  • Phone: 802-225-7000
  • Fax:
Mailing address:
  • Phone: 802-225-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0107967
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: