Provider Demographics
NPI:1073275814
Name:REYNOSO, BRANDICE MARIE (APRN-BC)
Entity Type:Individual
Prefix:
First Name:BRANDICE
Middle Name:MARIE
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15432 SPOTTED STALLION TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32234-2398
Mailing Address - Country:US
Mailing Address - Phone:904-955-7560
Mailing Address - Fax:
Practice Address - Street 1:15432 SPOTTED STALLION TRL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32234-2398
Practice Address - Country:US
Practice Address - Phone:904-955-7560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11015586363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily