Basic Information
| Provider Information | |||||||||
| NPI: | 1730156209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COMPO | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
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| Credential: | WHNP | ||||||||
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| OtherLastName: | COMPO | ||||||||
| OtherFirstName: | RENEE | ||||||||
| OtherMiddleName: | B | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S | ||||||||
| Address2: | MS21110Q | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528835375 | ||||||||
| FaxNumber: | 9525956455 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 GAMBLE DR SUITE 100 | ||||||||
| Address2: | MAIL STOP 31200A HEALTH PARTNERS WEST CLINIC | ||||||||
| City: | ST. LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554161582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525412500 | ||||||||
| FaxNumber: | 9525956455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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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 | 363L00000X | 0635226 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 989740200 | 05 | MN | MEDICAID |