Provider Demographics
NPI:1609078393
Name:REYNOLDS, ALICIA D (RD)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:D
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 MC CLELLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1626
Mailing Address - Country:US
Mailing Address - Phone:417-659-6481
Mailing Address - Fax:417-659-6548
Practice Address - Street 1:2727 MC CLELLAND BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1626
Practice Address - Country:US
Practice Address - Phone:417-659-6481
Practice Address - Fax:417-659-6548
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005033042133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered