Healthcare Provider Details

I. General information

NPI: 1962914366
Provider Name (Legal Business Name): ISHARON BENYETTE REYNOLDS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 WOODWARD AVE STE 1200
DETROIT MI
48201-3415
US

IV. Provider business mailing address

3100 S GREYFRIAR ST
DETROIT MI
48217-1072
US

V. Phone/Fax

Practice location:
  • Phone: 313-488-4332
  • Fax: 313-488-4332
Mailing address:
  • Phone: 313-629-9330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704361588
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.023310
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: