Provider Demographics
NPI:1154744977
Name:IOSSI, REN M
Entity type:Individual
Prefix:
First Name:REN
Middle Name:M
Last Name:IOSSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REN
Other - Middle Name:
Other - Last Name:WALCZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 540
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3678
Mailing Address - Country:US
Mailing Address - Phone:414-649-3240
Mailing Address - Fax:
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 540
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3678
Practice Address - Country:US
Practice Address - Phone:414-649-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5301363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner