Healthcare Provider Details

I. General information

NPI: 1760530521
Provider Name (Legal Business Name): RENEE M RENNICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WHEELING AVE
GLEN DALE WV
26038-1660
US

IV. Provider business mailing address

PO BOX 6826
WHEELING WV
26003-0921
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-3211
  • Fax:
Mailing address:
  • Phone: 304-242-7106
  • Fax: 304-242-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.002445
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.002445
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number718
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: