Provider Demographics
NPI:1174052476
Name:RENFRO, RACHELLE ENDRIGAN (LPN)
Entity type:Individual
Prefix:MRS
First Name:RACHELLE
Middle Name:ENDRIGAN
Last Name:RENFRO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:RACHELLE
Other - Middle Name:ENDRIGAN
Other - Last Name:STICKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 NE INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5544
Mailing Address - Country:US
Mailing Address - Phone:816-581-5899
Mailing Address - Fax:816-347-3046
Practice Address - Street 1:901 NE INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-5544
Practice Address - Country:US
Practice Address - Phone:816-581-5899
Practice Address - Fax:816-347-3046
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010028206164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1841235298Medicaid