Provider Demographics
NPI:1710217443
Name:REYNOLDS, TINA R (MS, RD, CDE)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:R
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 PRUDENTIAL DR
Mailing Address - Street 2:SUITE 416
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8210
Mailing Address - Country:US
Mailing Address - Phone:904-202-1553
Mailing Address - Fax:904-202-2462
Practice Address - Street 1:820 PRUDENTIAL DR
Practice Address - Street 2:SUITE 416
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8210
Practice Address - Country:US
Practice Address - Phone:904-202-1553
Practice Address - Fax:904-202-2462
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2254133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered