Provider Demographics
NPI:1285382002
Name:REYNOLDS, BRITTANY
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14415 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:DIXMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60426-1107
Mailing Address - Country:US
Mailing Address - Phone:708-960-4529
Mailing Address - Fax:708-312-5399
Practice Address - Street 1:4134 192ND CT
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-5808
Practice Address - Country:US
Practice Address - Phone:708-960-4529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3002146251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL881805300Medicaid