Provider Demographics
NPI:1609372028
Name:REYNOSO, MAGDA ELISA
Entity Type:Individual
Prefix:
First Name:MAGDA
Middle Name:ELISA
Last Name:REYNOSO
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 1:15015 122ND PL FL 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-4103
Mailing Address - Country:US
Mailing Address - Phone:917-204-1101
Mailing Address - Fax:
Practice Address - Street 1:15015 122ND PL FL 2
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-4103
Practice Address - Country:US
Practice Address - Phone:917-204-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator