Provider Demographics
NPI:1265608327
Name:REYNOSO, MISTY M (LMT)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:M
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19601 N 43RD DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7312
Mailing Address - Country:US
Mailing Address - Phone:623-640-8229
Mailing Address - Fax:
Practice Address - Street 1:34406 N 27TH DR
Practice Address - Street 2:SUITE 108
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6082
Practice Address - Country:US
Practice Address - Phone:623-266-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-06907173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist