Provider Demographics
NPI:1841605516
Name:REYNOLDS, AUTUMN NICOLE
Entity Type:Individual
Prefix:MS
First Name:AUTUMN
Middle Name:NICOLE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5422 EVERSON RD N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-5927
Mailing Address - Country:US
Mailing Address - Phone:614-743-4900
Mailing Address - Fax:
Practice Address - Street 1:5422 EVERSON RD N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-5927
Practice Address - Country:US
Practice Address - Phone:614-743-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-21
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-155698-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse