Provider Demographics
NPI:1902385974
Name:REYNOLDS, SABLE
Entity type:Individual
Prefix:
First Name:SABLE
Middle Name:
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 1:2611 GREENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3907
Mailing Address - Country:US
Mailing Address - Phone:218-212-2020
Mailing Address - Fax:318-212-6336
Practice Address - Street 1:2611 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3907
Practice Address - Country:US
Practice Address - Phone:218-212-2020
Practice Address - Fax:318-212-6336
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2024-11-19
Deactivation Date:2024-07-08
Deactivation Code:
Reactivation Date:2024-11-14
Provider Licenses
StateLicense IDTaxonomies
LA344178363A00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant