=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437141579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENEE LYNN WALDEN OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2005
-----------------------------------------------------
Last Update Date | 04/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8201 MISH KO SWEN DR
-----------------------------------------------------
City | CRANDON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54520-8631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-478-4300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9188 GOLF VIEW DR
-----------------------------------------------------
City | MINOCQUA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54548-9268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-358-1978
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1482DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3068-035
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------