Provider Demographics
NPI:1144200551
Name:HARGIS-REYNOLDS, DIANE (CNM)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:HARGIS-REYNOLDS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 HURFFVILLE CROSSKEYS RD STE 202
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-9344
Mailing Address - Country:US
Mailing Address - Phone:856-589-1414
Mailing Address - Fax:856-256-5772
Practice Address - Street 1:405 HURFFVILLE CROSSKEYS RD STE 202
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-9344
Practice Address - Country:US
Practice Address - Phone:856-589-1414
Practice Address - Fax:856-256-5772
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25ME00007201367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2529106Medicaid
NJ012151AEEMedicare PIN
NJS60070Medicare UPIN