Provider Demographics
NPI:1124302500
Name:REYNOLDS-HENRY, MARSHA A (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MARSHA
Middle Name:A
Last Name:REYNOLDS-HENRY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MARSHA
Other - Middle Name:
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:3944A PAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-4713
Mailing Address - Country:US
Mailing Address - Phone:917-723-4383
Mailing Address - Fax:347-326-8571
Practice Address - Street 1:3944A PAULDING AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-4713
Practice Address - Country:US
Practice Address - Phone:917-723-4383
Practice Address - Fax:347-326-8571
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY553414163W00000X
NYF343532-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02913711Medicaid