Provider Demographics
NPI:1174168710
Name:SMITH, RENEE R (CNM,APNP)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNM,APNP
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:R
Other - Last Name:DETTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM, APNP
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:720 S VANBUREN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3504
Practice Address - Country:US
Practice Address - Phone:920-433-3420
Practice Address - Fax:920-338-6859
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI148970-32367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CNM05317OtherAMERICAN MIDWIFERY CERTIFICATION