Basic Information
| Provider Information | |||||||||
| NPI: | 1205271434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENEAU | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MINICK | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 755 N. 11TH STREET | ||||||||
| Address2: | P2200 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098921192 | ||||||||
| FaxNumber: | 4099247511 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 N. 11TH STREET | ||||||||
| Address2: | P2200 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098921192 | ||||||||
| FaxNumber: | 4099247511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2013 | ||||||||
| LastUpdateDate: | 01/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 755876 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 755876 | 01 | TX | APN | OTHER |