Provider Demographics
NPI:1023202595
Name:REYNOLDS, GINA MAUREEN (RN)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MAUREEN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RN
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 1086
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46546-1086
Mailing Address - Country:US
Mailing Address - Phone:574-256-7308
Mailing Address - Fax:574-256-7314
Practice Address - Street 1:5555 GLENDON CT
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-3249
Practice Address - Country:US
Practice Address - Phone:574-256-7308
Practice Address - Fax:574-256-7314
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28111264A163WC0400X
OH00019239163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2811264AOtherINDIANA RN LICENSE