Provider Demographics
NPI:1528636859
Name:REYNOLDS, BRIAN JOSEPH (APNP/NP)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOSEPH
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:APNP/NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3816 89TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2592
Mailing Address - Country:US
Mailing Address - Phone:262-287-2845
Mailing Address - Fax:
Practice Address - Street 1:7619 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-1519
Practice Address - Country:US
Practice Address - Phone:262-287-2845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11003-33363LP0808X
WI11003363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health