Provider Demographics
NPI:1467843482
Name:REYNOLDS, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
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 1:2638 WENDE RD
Mailing Address - Street 2:
Mailing Address - City:ALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14004-9315
Mailing Address - Country:US
Mailing Address - Phone:716-481-2248
Mailing Address - Fax:
Practice Address - Street 1:2638 WENDE RD
Practice Address - Street 2:
Practice Address - City:ALDEN
Practice Address - State:NY
Practice Address - Zip Code:14004-9315
Practice Address - Country:US
Practice Address - Phone:716-481-2248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017775225X00000X
SC4684225X00000X
CA14677225X00000X
FL17955225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist