Healthcare Provider Details

I. General information

NPI: 1053468694
Provider Name (Legal Business Name): LYNDA FRANKENA REAGAN P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 BOSTWICK RD
OXFORD GA
30054-2834
US

IV. Provider business mailing address

190 BOSTWICK RD
OXFORD GA
30054-2834
US

V. Phone/Fax

Practice location:
  • Phone: 770-784-1893
  • Fax: 770-784-1893
Mailing address:
  • Phone: 770-784-1893
  • Fax: 770-784-1893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number002437
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: