Healthcare Provider Details

I. General information

NPI: 1265608327
Provider Name (Legal Business Name): MISTY M. REYNOSO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34406 N 27TH DR SUITE 108
PHOENIX AZ
85085-6082
US

IV. Provider business mailing address

19601 N 43RD DR
GLENDALE AZ
85308-7312
US

V. Phone/Fax

Practice location:
  • Phone: 623-266-1700
  • Fax:
Mailing address:
  • Phone: 623-640-8229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberMT-06907
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: