Provider Demographics
NPI:1538514328
Name:REID, JOHNNIE WYATTE
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:WYATTE
Last Name:REID
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 1:4727 ROSECROFT ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3029
Mailing Address - Country:US
Mailing Address - Phone:757-816-0622
Mailing Address - Fax:757-467-5257
Practice Address - Street 1:4727 ROSECROFT ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3029
Practice Address - Country:US
Practice Address - Phone:757-816-0622
Practice Address - Fax:757-467-5257
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA420171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor