Provider Demographics
NPI:1316712029
Name:REYNOLDS, AMY NICOLE
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
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 1:296 DISCIPLE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-1804
Mailing Address - Country:US
Mailing Address - Phone:601-917-8791
Mailing Address - Fax:
Practice Address - Street 1:604 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4108
Practice Address - Country:US
Practice Address - Phone:601-473-2106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator