Provider Demographics
NPI:1760121305
Name:REYNICKE, NICKY
Entity Type:Individual
Prefix:MR
First Name:NICKY
Middle Name:
Last Name:REYNICKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 CITY WALK PL APT 1
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-6661
Mailing Address - Country:US
Mailing Address - Phone:727-492-4097
Mailing Address - Fax:
Practice Address - Street 1:1411 E 31ST ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1092
Practice Address - Country:US
Practice Address - Phone:510-437-4881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95042307163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty