Provider Demographics
NPI:1063719110
Name:REYNOLDS, TAMARA ARLEEN (RD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:ARLEEN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:A
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1780 HANSHAW RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-257-5858
Practice Address - Fax:607-257-1718
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006613133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400040423Medicare PIN