Provider Demographics
NPI:1922655885
Name:PERNELL, REGINALD
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:PERNELL
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 1:1650 HOWLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-5318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 HOWLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-5318
Practice Address - Country:US
Practice Address - Phone:352-364-3475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP654-733-64--144-0172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver