Provider Demographics
NPI:1437170800
Name:REYNOLDS, CONNIE MARION (APRN BC)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:MARION
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 FOREST DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615
Mailing Address - Country:US
Mailing Address - Phone:423-794-6595
Mailing Address - Fax:423-477-0310
Practice Address - Street 1:2102 FOREST DR
Practice Address - Street 2:SUITE 5
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615
Practice Address - Country:US
Practice Address - Phone:423-794-6595
Practice Address - Fax:423-477-0310
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12126363LP0808X
TNAPN0000012126363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I507571Medicare PIN
TNQ75936Medicare UPIN