Provider Demographics
NPI:1386412617
Name:DALLAS, RENEE LYNN (CRNP)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:LYNN
Last Name:DALLAS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 HIGHLAND PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-1440
Mailing Address - Country:US
Mailing Address - Phone:814-935-1314
Mailing Address - Fax:
Practice Address - Street 1:OPTUM CARE SERVICES COMPANY
Practice Address - Street 2:
Practice Address - City:680 BLAIR MILL ROAD
Practice Address - State:PA
Practice Address - Zip Code:19044
Practice Address - Country:US
Practice Address - Phone:999-999-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN667379363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care