Healthcare Provider Details

I. General information

NPI: 1902385974
Provider Name (Legal Business Name): SABLE REYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date: 07/08/2024
Reactivation Date: 11/14/2024

III. Provider practice location address

2611 GREENWOOD RD
SHREVEPORT LA
71103-3907
US

IV. Provider business mailing address

2611 GREENWOOD RD
SHREVEPORT LA
71103-3907
US

V. Phone/Fax

Practice location:
  • Phone: 218-212-2020
  • Fax: 318-212-6336
Mailing address:
  • Phone: 218-212-2020
  • Fax: 318-212-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number344178
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: