Provider Demographics
NPI:1164747317
Name:REYNOLDS, MELISSA L (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:L
Other - Last Name:MCCONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:USA MEDDAC
Mailing Address - Street 2:11050 MT. BELVEDERE BLVD.
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-772-2778
Mailing Address - Fax:315-965-3703
Practice Address - Street 1:USA MEDDAC
Practice Address - Street 2:11050 MT. BELVEDERE BLVD.
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-2778
Practice Address - Fax:315-965-3703
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336340363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily