Provider Demographics
NPI:1386519544
Name:REYNOSO, TANYA M
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:REYNOSO
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 1:2921 WALDORF AVE
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08105-2821
Mailing Address - Country:US
Mailing Address - Phone:856-206-6467
Mailing Address - Fax:
Practice Address - Street 1:2921 WALDORF AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08105-2821
Practice Address - Country:US
Practice Address - Phone:856-206-6467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-08
Last Update Date:2025-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist