Provider Demographics
NPI:1538247044
Name:RENEAU, HEIDI HALE (CNM)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:HALE
Last Name:RENEAU
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:HALE
Other - Last Name:PITCHLYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:100 S BLISS AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2512
Mailing Address - Country:US
Mailing Address - Phone:918-458-3360
Mailing Address - Fax:918-458-3511
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3360
Practice Address - Fax:918-458-3511
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS64067367A00000X
OK101498367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200111380AMedicaid
OKQ43382Medicare UPIN
OK8HD704Medicare PIN