Provider Demographics
NPI:1356824098
Name:REYNOLDS, MARY BETH (FNP-BC, APNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:FNP-BC, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N292 LAMER DR
Mailing Address - Street 2:
Mailing Address - City:OGEMA
Mailing Address - State:WI
Mailing Address - Zip Code:54459-8764
Mailing Address - Country:US
Mailing Address - Phone:715-767-5199
Mailing Address - Fax:
Practice Address - Street 1:1511 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:PRENTICE
Practice Address - State:WI
Practice Address - Zip Code:54556-1155
Practice Address - Country:US
Practice Address - Phone:715-428-2521
Practice Address - Fax:715-428-2522
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8691-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily