Provider Demographics
NPI:1265647515
Name:REYNOLDS, SHANDERA D
Entity Type:Individual
Prefix:
First Name:SHANDERA
Middle Name:D
Last Name:REYNOLDS
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 1:23702 E BAINTREE RD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-1254
Mailing Address - Country:US
Mailing Address - Phone:216-381-3578
Mailing Address - Fax:
Practice Address - Street 1:23702 E BAINTREE RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-1254
Practice Address - Country:US
Practice Address - Phone:216-381-3578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2640020Medicaid