Provider Demographics
NPI:1235379660
Name:REYNOLDS, MICKIE R (RN)
Entity Type:Individual
Prefix:
First Name:MICKIE
Middle Name:R
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 WINGFIELD ST
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-9327
Mailing Address - Country:US
Mailing Address - Phone:505-257-4577
Mailing Address - Fax:
Practice Address - Street 1:506 WINGFIELD ST
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-9327
Practice Address - Country:US
Practice Address - Phone:505-257-4577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3271251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM327205Medicare Oscar/Certification