Provider Demographics
NPI:1043633985
Name:RENNER, STACEY FAVRE (APRN)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:FAVRE
Last Name:RENNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 N POINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-4102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 OLD HIGHWAY 96 STE B
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005-3461
Practice Address - Country:US
Practice Address - Phone:478-352-7143
Practice Address - Fax:478-352-7144
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170160363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily