Provider Demographics
NPI:1194962241
Name:REYNOLDS, MARY K (ARNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:K
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 W GRANADA BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8165
Mailing Address - Country:US
Mailing Address - Phone:386-677-2606
Mailing Address - Fax:386-672-5341
Practice Address - Street 1:1180 W GRANADA BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8165
Practice Address - Country:US
Practice Address - Phone:386-677-2606
Practice Address - Fax:386-672-5341
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3269632363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily