Provider Demographics
NPI:1790892040
Name:REYNOLDS, KRISTEN H (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:H
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:HAKES
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:8320 W BLUEMOUND RD
Practice Address - Street 2:#125
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-3367
Practice Address - Country:US
Practice Address - Phone:414-302-3800
Practice Address - Fax:414-302-3813
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34012600Medicaid
BH6888688OtherDEA NUMBER
BH6888688OtherDEA NUMBER