Provider Demographics
NPI:1336893692
Name:REYNOLDS, JUSTIN ALAN (ACNP)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ALAN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6750 E BAYWOOD AVE # 401
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1749
Mailing Address - Country:US
Mailing Address - Phone:480-835-7111
Mailing Address - Fax:480-969-9345
Practice Address - Street 1:6750 E BAYWOOD AVE # 401
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1749
Practice Address - Country:US
Practice Address - Phone:480-835-7111
Practice Address - Fax:480-969-9345
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY1144183163WG0000X
AZ270825363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice