Provider Demographics
NPI:1659601771
Name:REYNOLDS, GEORGIA
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
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 1:526 GAFFNEY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4914
Mailing Address - Country:US
Mailing Address - Phone:907-479-7940
Mailing Address - Fax:907-474-4052
Practice Address - Street 1:526 GAFFNEY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4914
Practice Address - Country:US
Practice Address - Phone:907-479-7940
Practice Address - Fax:907-474-4052
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator