Provider Demographics
NPI:1619154697
Name:REYNOLDS, MICHELE MARIE (RD, LD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 ENCLAVE DR.
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503
Mailing Address - Country:US
Mailing Address - Phone:606-202-2320
Mailing Address - Fax:
Practice Address - Street 1:2441 S HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-2935
Practice Address - Country:US
Practice Address - Phone:606-677-4068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC922938133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered