Provider Demographics
NPI:1013461300
Name:REYNOLDS, NATALIE
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:
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 1:19735 FAUST AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-2116
Mailing Address - Country:US
Mailing Address - Phone:313-595-3066
Mailing Address - Fax:
Practice Address - Street 1:19735 FAUST AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-2116
Practice Address - Country:US
Practice Address - Phone:313-595-3066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703105656164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse