Provider Demographics
NPI:1447039516
Name:RENNER, LAURA CHRISTINE (NP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:CHRISTINE
Last Name:RENNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9712 S 200 W
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:IN
Practice Address - Zip Code:46118
Practice Address - Country:US
Practice Address - Phone:317-948-3200
Practice Address - Fax:317-217-2424
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP001697363LF0000X
IN71015264A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1104414760OtherANTHEM PTAN
IN300095323Medicaid