Provider Demographics
NPI:1942858527
Name:REYNOSO, YVETTE ALTAGRACIA
Entity Type:Individual
Prefix:MS
First Name:YVETTE
Middle Name:ALTAGRACIA
Last Name:REYNOSO
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 1:37 COOLIDGE PL
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1307
Mailing Address - Country:US
Mailing Address - Phone:201-245-8171
Mailing Address - Fax:
Practice Address - Street 1:655 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-1398
Practice Address - Country:US
Practice Address - Phone:908-352-8375
Practice Address - Fax:908-352-8858
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ221487364390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program