Provider Demographics
NPI:1013618271
Name:REYNOLDS, SLADE IAN (RN)
Entity Type:Individual
Prefix:
First Name:SLADE
Middle Name:IAN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 ELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-3405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1203 MAPLE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6910
Practice Address - Country:US
Practice Address - Phone:336-908-6243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC290973163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse