Provider Demographics
NPI:1205271434
Name:RENEAU, AMANDA MINICK (APN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MINICK
Last Name:RENEAU
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 N. 11TH STREET
Mailing Address - Street 2:P2200
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1513
Mailing Address - Country:US
Mailing Address - Phone:409-892-1192
Mailing Address - Fax:409-924-7511
Practice Address - Street 1:755 N. 11TH STREET
Practice Address - Street 2:P2200
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1513
Practice Address - Country:US
Practice Address - Phone:409-892-1192
Practice Address - Fax:409-924-7511
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX755876363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX755876OtherAPN