Healthcare Provider Details

I. General information

NPI: 1679931760
Provider Name (Legal Business Name): STACY L REYNOLDS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 ADCOCK RD STE A
HOT SPRINGS AR
71913
US

IV. Provider business mailing address

1661 AIRPORT RD STE D
HOT SPRINGS AR
71913-8184
US

V. Phone/Fax

Practice location:
  • Phone: 501-651-4500
  • Fax: 501-651-4510
Mailing address:
  • Phone: 501-625-7500
  • Fax: 501-625-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA004638
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: