Healthcare Provider Details

I. General information

NPI: 1316632706
Provider Name (Legal Business Name): SHANEKA REYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE RM 316E
MIAMI FL
33136-1005
US

IV. Provider business mailing address

11031 REDHAWK ST
PLANTATION FL
33324-2167
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-5578
  • Fax:
Mailing address:
  • Phone: 786-356-1457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11012659
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11012659
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: