Provider Demographics
NPI:1124376355
Name:REYNOLDS, NICOLE MARIE (PA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8602
Mailing Address - Fax:
Practice Address - Street 1:340 MEDICAL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2441
Practice Address - Country:US
Practice Address - Phone:864-797-7940
Practice Address - Fax:864-797-9402
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106821363A00000X
SC3979363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1238631OtherWELLCARE
FL7770991OtherAETNA
FLP1020252OtherFREEDOM
FL009562900Medicaid
FL8581438OtherCIGNA
FLY0J43OtherBCBS OF FL
FLP958818OtherOPTIMUM
FL398634OtherAVMED
FL7770991OtherAETNA
FL8581438OtherCIGNA
FL1238631OtherWELLCARE
FL009562900Medicaid