Provider Demographics
NPI:1538146949
Name:REYNOLDS, SHALI M (ANP)
Entity type:Individual
Prefix:
First Name:SHALI
Middle Name:M
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 MALLARD LOOP RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-8123
Mailing Address - Country:US
Mailing Address - Phone:912-450-1160
Mailing Address - Fax:912-450-3971
Practice Address - Street 1:125 SOUTHERN JUNCTION BLVD STE 201
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2214
Practice Address - Country:US
Practice Address - Phone:912-450-1160
Practice Address - Fax:912-450-3971
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN140169363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA705938810NMedicaid
GA705938810NMedicaid
GA20250I2846Medicare PIN
GA705938810LMedicaid
GAP01020918OtherRAILROAD MEDICARE
GA705938810IMedicaid
GA50BBHZDMedicare PIN
GA705938810JMedicaid
GA705938810GMedicaid
GA705938810HMedicaid
GA705938810MMedicaid
GA705938810KMedicaid