Provider Demographics
NPI:1992265334
Name:REYNOLDS, PETAGAYE LATOYA
Entity type:Individual
Prefix:
First Name:PETAGAYE
Middle Name:LATOYA
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 1:1441 GRINDSTONE DR SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-9446
Mailing Address - Country:US
Mailing Address - Phone:707-724-9578
Mailing Address - Fax:
Practice Address - Street 1:320 176TH ST E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8322
Practice Address - Country:US
Practice Address - Phone:253-683-7400
Practice Address - Fax:253-683-7498
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60869053163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool