Provider Demographics
NPI:1215563523
Name:REYNOSO, JULISSA
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 W 37TH ST FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-5193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:247 W 37TH ST FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-5193
Practice Address - Country:US
Practice Address - Phone:212-273-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator