Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1134895121 |
---|---|
Provider Name | Rena Nevels |
First Address | Fridley, MN 55432-4824 |
Second Address | Fridley, MN 55432-4824 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2021 |
Last Update Date | 19/08/2021 |