Provider Demographics
NPI:1689462012
Name:REYNOLDS, PHOENIX DAWN
Entity type:Individual
Prefix:MS
First Name:PHOENIX
Middle Name:DAWN
Last Name:REYNOLDS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8340 SW 65TH AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-7948
Mailing Address - Country:US
Mailing Address - Phone:786-521-5824
Mailing Address - Fax:
Practice Address - Street 1:8340 SW 65TH AVE APT 7
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-7948
Practice Address - Country:US
Practice Address - Phone:786-521-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-26
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11039061363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty