Provider Demographics
NPI:1629617774
Name:REYNOLDS, CHARLENE (APRN)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 SHADOWOOD LN STE 106
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1636 SHADOWOOD LN STE 106
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2187
Practice Address - Country:US
Practice Address - Phone:904-695-0249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9423089163W00000X
IL041431448163W00000X
IL209022748363LP0808X
FLAPRN11009388363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108934400Medicaid