Provider Demographics
NPI:1548517956
Name:MATHEW, RENEE MARIE (APRN)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:MARIE
Last Name:MATHEW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:M
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 18667
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-0667
Mailing Address - Country:US
Mailing Address - Phone:859-572-3617
Mailing Address - Fax:859-572-2326
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100219530Medicaid
OH0224891Medicaid