Provider Demographics
NPI:1396317251
Name:PHAM-REYNOLDS, FALLAN
Entity type:Individual
Prefix:
First Name:FALLAN
Middle Name:
Last Name:PHAM-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 1:7545 OLD FIELD COVE RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-8938
Mailing Address - Country:US
Mailing Address - Phone:678-983-0103
Mailing Address - Fax:
Practice Address - Street 1:147 REINHARDT COLLEGE PKWY STE 9
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5295
Practice Address - Country:US
Practice Address - Phone:770-345-3057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist