Provider Demographics
NPI:1215996277
Name:REYNOLDS, LISA DAWN (FNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DAWN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:DAWN
Other - Last Name:GREGOIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10400 EATON PLACE
Mailing Address - Street 2:STE 410
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030
Mailing Address - Country:US
Mailing Address - Phone:703-359-5160
Mailing Address - Fax:703-383-9574
Practice Address - Street 1:410 MAPLE AVE WEST
Practice Address - Street 2:STE 5
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180
Practice Address - Country:US
Practice Address - Phone:703-938-2244
Practice Address - Fax:703-938-3669
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164882363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner