Provider Demographics
NPI:1437673126
Name:REYNOLDS, MARY NGUYEN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NGUYEN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:225 MEDICAL CENTER DR STE 405
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7914
Mailing Address - Country:US
Mailing Address - Phone:270-441-4750
Mailing Address - Fax:270-441-4770
Practice Address - Street 1:225 MEDICAL CENTER DR STE 405
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7914
Practice Address - Country:US
Practice Address - Phone:270-441-4750
Practice Address - Fax:270-441-4770
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK134581367500000X
KY3011688367500000X
IN28203709A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3011688OtherKENTUCKY APRN LICENSE