Provider Demographics
NPI:1023461001
Name:REYNOLDS, MARY ALYCE (LPN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALYCE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ALYCE
Other - Last Name:BIESTERFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4025 RAWLINS ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1900
Mailing Address - Country:US
Mailing Address - Phone:307-426-4797
Mailing Address - Fax:307-426-3449
Practice Address - Street 1:975 GILCHRIST ST
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:WY
Practice Address - Zip Code:82201-2931
Practice Address - Country:US
Practice Address - Phone:307-322-8122
Practice Address - Fax:307-322-3449
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8596171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator