Provider Demographics
NPI:1326083460
Name:REYNOLDS COOLEY, LYNN M
Entity Type:Individual
Prefix:MS
First Name:LYNN
Middle Name:M
Last Name:REYNOLDS COOLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6002
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTH COLUMBIA ROAD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58206-6002
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR23311163W00000X, 367H00000X, 367500000X
NE100859367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000098Medicare Oscar/Certification