Provider Demographics
NPI:1598844888
Name:REYNOLDS, NANCY JANE (MD FACOG)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:JANE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD FACOG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2762
Mailing Address - Street 2:
Mailing Address - City:FT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:707-962-0993
Practice Address - Street 1:5176 HILL RD EAST
Practice Address - Street 2:SUTTER LAKESIDE HOSPITAL FAMILY MEDICINE WOMENS
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453
Practice Address - Country:US
Practice Address - Phone:707-262-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41803207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G418030Medicaid
00G418030OtherBCBS
7090022OtherCOMMERCIAL
00G418030OtherBCBS
00G418030Medicare ID - Type Unspecified