Provider Demographics
NPI:1841156577
Name:REYNOLDS, CHANTIA (AGACNP)
Entity type:Individual
Prefix:
First Name:CHANTIA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 DERRICK RD APT 5108
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-1956
Mailing Address - Country:US
Mailing Address - Phone:404-626-3330
Mailing Address - Fax:
Practice Address - Street 1:4770 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470-1136
Practice Address - Country:US
Practice Address - Phone:718-931-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-26
Last Update Date:2025-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANP237254363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty