Provider Demographics
NPI:1497073811
Name:REYNOLDS, JANNELLE GWYNETH (PA-C)
Entity Type:Individual
Prefix:
First Name:JANNELLE
Middle Name:GWYNETH
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 UNIVERISTY DR
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68849-2217
Mailing Address - Country:US
Mailing Address - Phone:970-214-3570
Mailing Address - Fax:
Practice Address - Street 1:2510 11TH AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68849-2247
Practice Address - Country:US
Practice Address - Phone:970-214-3570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20862363A00000X
KS15-01382363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant