Provider Demographics
NPI:1750414611
Name:REYNOLDS, ELEANOR MAE (LPN)
Entity type:Individual
Prefix:MRS
First Name:ELEANOR
Middle Name:MAE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:ELEANOR
Other - Middle Name:MAE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:246 MASON RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPLAIN
Mailing Address - State:NY
Mailing Address - Zip Code:12919-6202
Mailing Address - Country:US
Mailing Address - Phone:518-298-8554
Mailing Address - Fax:
Practice Address - Street 1:2739 RT 11
Practice Address - Street 2:
Practice Address - City:MOOERS
Practice Address - State:NY
Practice Address - Zip Code:12958-2739
Practice Address - Country:US
Practice Address - Phone:518-236-7241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090251-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02755902Medicaid