Healthcare Provider Details

I. General information

NPI: 1063650455
Provider Name (Legal Business Name): AMY LYNN REYNOLDS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E HANOVER ST
NEW BADEN IL
62265-1811
US

IV. Provider business mailing address

211 E HANOVER ST
NEW BADEN IL
62265-1811
US

V. Phone/Fax

Practice location:
  • Phone: 618-588-2900
  • Fax: 618-588-2904
Mailing address:
  • Phone: 618-588-2900
  • Fax: 618-588-2904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017016291
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number309004087
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: