Provider Demographics
NPI:1366095242
Name:WIGGINTON, RENEKA SHAVON (APRN)
Entity type:Individual
Prefix:MRS
First Name:RENEKA
Middle Name:SHAVON
Last Name:WIGGINTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2216
Mailing Address - Country:US
Mailing Address - Phone:502-595-7744
Mailing Address - Fax:502-595-7007
Practice Address - Street 1:716 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2216
Practice Address - Country:US
Practice Address - Phone:502-595-7744
Practice Address - Fax:502-595-7007
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013441363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner