Provider Demographics
NPI:1346389319
Name:REYNOLDS, KATY L (MD)
Entity Type:Individual
Prefix:DR
First Name:KATY
Middle Name:L
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 KEY ST
Mailing Address - Street 2:
Mailing Address - City:MILLIS
Mailing Address - State:MA
Mailing Address - Zip Code:02054-1145
Mailing Address - Country:US
Mailing Address - Phone:850-607-1414
Mailing Address - Fax:
Practice Address - Street 1:15 MOHEGAN AVENUE
Practice Address - Street 2:UNITED STATES COAST GUARD ACADEMY
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4195
Practice Address - Country:US
Practice Address - Phone:850-607-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57438261QM1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient