Provider Demographics
NPI:1154459287
Name:REYNOLDS, SUSAN JEAN (RN, CPNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:20652 FARNSWORTH LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-5522
Mailing Address - Country:US
Mailing Address - Phone:714-536-0348
Mailing Address - Fax:714-969-2647
Practice Address - Street 1:9802 WOODBURY AVE
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-2819
Practice Address - Country:US
Practice Address - Phone:714-663-6411
Practice Address - Fax:714-663-6470
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230910363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1458726OtherPIN#
CASS3066522OtherPROVIDER NUMBER