Provider Demographics
NPI:1417586025
Name:REYNOLDS, SHELLY ANN (LPN)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 WOODWARD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-0961
Mailing Address - Country:US
Mailing Address - Phone:248-395-3777
Mailing Address - Fax:
Practice Address - Street 1:28000 WOODWARD AVE STE 100
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0961
Practice Address - Country:US
Practice Address - Phone:248-395-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703051569164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703051569Medicaid