=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598025769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WYANETHA RENNER, MA,CCC/SLP, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2012
-----------------------------------------------------
Last Update Date | 05/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 LAKE BEAUTY DR STE 304
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-303-4320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2182 CRANDON AVE
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-3382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-303-4320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WYANETHA RENNNER
-----------------------------------------------------
Credential | MA,CCC/SLP
-----------------------------------------------------
Telephone | 321-303-4320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA6648
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------