Provider Demographics
NPI:1841824695
Name:REYNOLDS, SAMANTHA JENAE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JENAE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JENAE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2919 S. ELLSWORTH RD.
Mailing Address - Street 2:SUITE 135
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-2164
Mailing Address - Country:US
Mailing Address - Phone:480-967-6888
Mailing Address - Fax:480-967-6887
Practice Address - Street 1:2045 S. VINEYARD
Practice Address - Street 2:BLDG N3, SUITE 144
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210
Practice Address - Country:US
Practice Address - Phone:480-967-6888
Practice Address - Fax:480-967-6887
Is Sole Proprietor?:No
Enumeration Date:2020-03-01
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ238475363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily