Provider Demographics
NPI:1033572938
Name:REYNOLDS, MELISSA L
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6500 HOSPITAL DR
Mailing Address - Street 2:2B
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6890
Mailing Address - Country:US
Mailing Address - Phone:573-629-3440
Mailing Address - Fax:573-629-3423
Practice Address - Street 1:6500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6890
Practice Address - Country:US
Practice Address - Phone:573-629-3440
Practice Address - Fax:573-629-3423
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015043764363LA2200X, 363LG0600X, 363LP2300X
IL209013822363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400286954Medicare PIN