Provider Demographics
NPI:1417669946
Name:REYNOLDS, SHANNA R (IBCLC)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:R
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 BUFFALO RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FERRUM
Mailing Address - State:VA
Mailing Address - Zip Code:24088-3230
Mailing Address - Country:US
Mailing Address - Phone:540-238-4045
Mailing Address - Fax:
Practice Address - Street 1:1764 BUFFALO RIDGE RD
Practice Address - Street 2:
Practice Address - City:FERRUM
Practice Address - State:VA
Practice Address - Zip Code:24088-3230
Practice Address - Country:US
Practice Address - Phone:540-238-4045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAL-309868174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN