Provider Demographics
NPI:1407954696
Name:REYNOLDS, TANYA RUTH (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:RUTH
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 N MANATEE ST
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-1513
Mailing Address - Country:US
Mailing Address - Phone:812-531-1127
Mailing Address - Fax:
Practice Address - Street 1:3 N MANATEE ST
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-1513
Practice Address - Country:US
Practice Address - Phone:812-531-1127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001528A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200427630Medicaid