Provider Demographics
NPI:1225377419
Name:REYNOLDS, EMILY GORDON (MS, RD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:GORDON
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 W 24TH STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YUMA
Mailing Address - State:ARIZONA
Mailing Address - Zip Code:85364
Mailing Address - Country:UM
Mailing Address - Phone:928-329-8331
Mailing Address - Fax:928-329-8528
Practice Address - Street 1:1220 W 24TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8705
Practice Address - Country:US
Practice Address - Phone:928-329-8331
Practice Address - Fax:928-329-8528
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL998200133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered