Provider Demographics
NPI:1568979847
Name:REYNOLDS, DORENE B
Entity Type:Individual
Prefix:MS
First Name:DORENE
Middle Name:B
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 1:7057 EUCLID CHARDON RD
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9428
Mailing Address - Country:US
Mailing Address - Phone:440-429-9760
Mailing Address - Fax:
Practice Address - Street 1:7057 EUCLID CHARDON RD
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:OH
Practice Address - Zip Code:44094-9428
Practice Address - Country:US
Practice Address - Phone:440-429-9760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02383573747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0238357Medicaid