Provider Demographics
NPI:1982355582
Name:REYNOLDS, KIMBERLY IRETTA (LPN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:IRETTA
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 EVERGLADE CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73128-7009
Mailing Address - Country:US
Mailing Address - Phone:918-525-7377
Mailing Address - Fax:
Practice Address - Street 1:1703 EVERGLADE CT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73128-7009
Practice Address - Country:US
Practice Address - Phone:918-525-7377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP053468164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse