Provider Demographics
NPI:1124201165
Name:REYNOLDS, LISA MARIE (APRN, BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:REYNOLDS
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 1:1448 10TH AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3579
Mailing Address - Country:US
Mailing Address - Phone:304-691-1000
Mailing Address - Fax:304-399-2526
Practice Address - Street 1:1249 15TH ST STE 3000
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3663
Practice Address - Country:US
Practice Address - Phone:304-691-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV61789363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4248261Medicare PIN