Provider Demographics
NPI:1063838654
Name:REYNOLDS, LORA DIANE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LORA
Middle Name:DIANE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:FNP
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Other - Credentials:
Mailing Address - Street 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:SUITE 313
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7659
Mailing Address - Country:US
Mailing Address - Phone:276-258-3780
Mailing Address - Fax:276-258-3776
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:SUITE 313
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7659
Practice Address - Country:US
Practice Address - Phone:276-258-3780
Practice Address - Fax:276-258-3776
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024171491363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1063838654Medicaid
VAP01502220OtherRAILROAD MEDICARE
VAP01502220OtherRAILROAD MEDICARE