Provider Demographics
NPI:1144832981
Name:4 CORNERS CHILDREN'S CLINIC
Entity type:Organization
Organization Name:4 CORNERS CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPNP
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENSNER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:970-335-9678
Mailing Address - Street 1:555 RIVERGATE STE B1-109
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7473
Mailing Address - Country:US
Mailing Address - Phone:970-335-9678
Mailing Address - Fax:
Practice Address - Street 1:555 RIVERGATE STE B1-109
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7473
Practice Address - Country:US
Practice Address - Phone:970-335-9678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty