Provider Demographics
NPI:1013462001
Name:REYNOLDS-BARNES, DELECA LATRICE
Entity Type:Individual
Prefix:
First Name:DELECA
Middle Name:LATRICE
Last Name:REYNOLDS-BARNES
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 1:2401 EDGE O LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-5755
Mailing Address - Country:US
Mailing Address - Phone:615-645-1892
Mailing Address - Fax:
Practice Address - Street 1:2401 EDGE O LAKE DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-5755
Practice Address - Country:US
Practice Address - Phone:615-645-1892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10608183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist