Provider Demographics
NPI:1073708830
Name:REYNOLDS, CLARISSA STEWART (COF)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:STEWART
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:COF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 791
Mailing Address - Street 2:
Mailing Address - City:HAMLET
Mailing Address - State:NC
Mailing Address - Zip Code:28345-0791
Mailing Address - Country:US
Mailing Address - Phone:910-582-1776
Mailing Address - Fax:910-582-2506
Practice Address - Street 1:41 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMLET
Practice Address - State:NC
Practice Address - Zip Code:28345-3629
Practice Address - Country:US
Practice Address - Phone:910-582-1776
Practice Address - Fax:910-582-2506
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225000000X
NCCFOM0714224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter