Provider Demographics
NPI:1962707687
Name:RENNER, CAROLYN MARIE (MS, RDN, LD)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:MARIE
Last Name:RENNER
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 INDIAN LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3057
Mailing Address - Country:US
Mailing Address - Phone:307-349-1297
Mailing Address - Fax:307-335-5065
Practice Address - Street 1:175 S 5TH ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3001
Practice Address - Country:US
Practice Address - Phone:307-349-1297
Practice Address - Fax:307-349-1297
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY004133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered