Provider Demographics
NPI:1972155174
Name:REYNOLDS, HALEY (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4152 BAKER ST NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-1404
Mailing Address - Country:US
Mailing Address - Phone:770-788-1077
Mailing Address - Fax:678-392-1202
Practice Address - Street 1:4152 BAKER ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1404
Practice Address - Country:US
Practice Address - Phone:770-788-1077
Practice Address - Fax:678-392-1202
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA230536363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics