Provider Demographics
NPI:1750319570
Name:REYNOLDS, PHYLLIS MACK (ANP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MACK
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0909
Mailing Address - Country:US
Mailing Address - Phone:847-566-0164
Mailing Address - Fax:847-566-0375
Practice Address - Street 1:201 E PARK ST
Practice Address - Street 2:UNIT B
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1973
Practice Address - Country:US
Practice Address - Phone:847-566-0164
Practice Address - Fax:847-566-0375
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse