Provider Demographics
NPI:1235384769
Name:REYNOLDS, NICOLE M (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 LONGBRANCH RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3213
Mailing Address - Country:US
Mailing Address - Phone:315-214-3431
Mailing Address - Fax:315-457-0403
Practice Address - Street 1:4205 LONGBRANCH RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3213
Practice Address - Country:US
Practice Address - Phone:315-214-3431
Practice Address - Fax:315-457-0403
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-25
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist