Healthcare Provider Details

I. General information

NPI: 1649901794
Provider Name (Legal Business Name): ASHLEY REYNOLDS RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY HENDERSON RN

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N WILMOT RD
TUCSON AZ
85711-2602
US

IV. Provider business mailing address

1215 E 13TH ST
TUCSON AZ
85719-6156
US

V. Phone/Fax

Practice location:
  • Phone: 520-873-1609
  • Fax:
Mailing address:
  • Phone: 520-250-5269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number206504
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-301844
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: