Basic Information
| Provider Information | |||||||||
| NPI: | 1417105800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRESTON | ||||||||
| FirstName: | RENAE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 MEDICAL CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496847823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319358000 | ||||||||
| FaxNumber: | 2319358099 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 MEDICAL CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496847823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319358000 | ||||||||
| FaxNumber: | 2319358099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2008 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704239937 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1417105800 | 05 | MI | MEDICAID |