Provider Demographics
NPI:1417478058
Name:REYNOLDS, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119D JOSEPH LONSWAY DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NY
Mailing Address - Zip Code:13624-9579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119D JOSEPH LONSWAY DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NY
Practice Address - Zip Code:13624-9579
Practice Address - Country:US
Practice Address - Phone:315-408-6479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308153164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse