Provider Demographics
NPI:1215062161
Name:REYNOLDS, PATRICIA (CNM, NP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:CNM, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6570
Mailing Address - Country:US
Mailing Address - Phone:770-898-1415
Mailing Address - Fax:770-898-2887
Practice Address - Street 1:906 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6570
Practice Address - Country:US
Practice Address - Phone:770-898-1415
Practice Address - Fax:770-898-2887
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN057361363LW0102X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00811522AMedicaid