Provider Demographics
NPI:1114672086
Name:REYNOLDS, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 FIRST MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31719-2336
Mailing Address - Country:US
Mailing Address - Phone:229-938-3872
Mailing Address - Fax:
Practice Address - Street 1:220 N. THOMPSON
Practice Address - Street 2:
Practice Address - City:ELLAVILLE
Practice Address - State:GA
Practice Address - Zip Code:31806-3180
Practice Address - Country:US
Practice Address - Phone:229-938-3872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care