Provider Demographics
NPI:1063836229
Name:REYNADO, LISA (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:REYNADO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:RUIDERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:9300 DEWITT LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-5285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9300 DEWITT LOOP
Practice Address - Street 2:
Practice Address - City:FT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5285
Practice Address - Country:US
Practice Address - Phone:571-231-1803
Practice Address - Fax:571-231-6617
Is Sole Proprietor?:No
Enumeration Date:2014-02-08
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23624363LF0000X
VA24172357363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily