Basic Information
| Provider Information | |||||||||
| NPI: | 1437141579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALDEN | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FEIT | ||||||||
| OtherFirstName: | RENEE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9188 GOLF VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MINOCQUA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545489268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153581978 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8201 MISH KO SWEN DR | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
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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 | 152W00000X | 1482DT | KY | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 3068-035 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 38643900 | 05 | WI | MEDICAID |