Provider Demographics
NPI:1609630649
Name:REYNOLDS, BRENDA MADALINE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:MADALINE
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 1:629 RACCOON RUN RD
Mailing Address - Street 2:
Mailing Address - City:LOST CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:26385-7220
Mailing Address - Country:US
Mailing Address - Phone:304-409-8532
Mailing Address - Fax:
Practice Address - Street 1:629 RACCOON RUN RD
Practice Address - Street 2:
Practice Address - City:LOST CREEK
Practice Address - State:WV
Practice Address - Zip Code:26385-7220
Practice Address - Country:US
Practice Address - Phone:304-409-8532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant