Provider Demographics
NPI:1043778947
Name:REYNOLDS, GABRIELLE MAUREEN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MAUREEN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12755 SW 47TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6053
Mailing Address - Country:US
Mailing Address - Phone:954-274-2591
Mailing Address - Fax:
Practice Address - Street 1:12755 SW 47TH ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6053
Practice Address - Country:US
Practice Address - Phone:954-274-2591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-09
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAG03190022363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care