Provider Demographics
NPI:1285492264
Name:MCREYNOLDS, MISTY SUE (RN)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:SUE
Last Name:MCREYNOLDS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 W 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-6618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2909 W 13TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-6618
Practice Address - Country:US
Practice Address - Phone:316-841-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS113726163W00000X
KS53-83356-112363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse