Provider Demographics
NPI:1477119691
Name:REYNOLDS, ALEXIS ARIEL
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ARIEL
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 1:361 NE MARTIN LUTHER KING ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-2118
Mailing Address - Country:US
Mailing Address - Phone:386-697-4194
Mailing Address - Fax:
Practice Address - Street 1:361 NE MARTIN LUTHER KING ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-2118
Practice Address - Country:US
Practice Address - Phone:386-697-4194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker