Provider Demographics
NPI:1306850268
Name:REYNOLDS, KRISTY S (MD)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:S
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:
Other - Last Name:SELF-REYNOLDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4094 MAJESTIC LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2104
Mailing Address - Country:US
Mailing Address - Phone:703-391-3996
Mailing Address - Fax:
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3027
Practice Address - Country:US
Practice Address - Phone:540-349-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236678207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010104734Medicaid
VA010119260Medicaid
I21069Medicare UPIN
VA010104734Medicaid
VAP00158483Medicare PIN
VA010119260Medicaid