Provider Demographics
NPI:1932178019
Name:REYNOLDS, PAMELA (FNPC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 WILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1630
Mailing Address - Country:US
Mailing Address - Phone:434-572-8921
Mailing Address - Fax:434-572-2063
Practice Address - Street 1:2212 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1630
Practice Address - Country:US
Practice Address - Phone:434-572-8921
Practice Address - Fax:434-572-2063
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA024164721363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007791992Medicaid
VA35419NOtherOPTIMA
VA35419NOtherOPTIMA
VA500001034Medicare ID - Type Unspecified