Provider Demographics
NPI:1689855678
Name:REYNOLDS, RENEE NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:NICOLE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:LARGENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:220 N SYKES CREEK PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 N SYKES CREEK PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3490
Practice Address - Country:US
Practice Address - Phone:321-459-1446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-18
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 19484225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant