Healthcare Provider Details

I. General information

NPI: 1053269878
Provider Name (Legal Business Name): KALEB ARDEN PURCELL REYNOLDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 NEW BERN AVE
RALEIGH NC
27610-1214
US

IV. Provider business mailing address

1880 AMOS ST
REIDSVILLE NC
27320-6204
US

V. Phone/Fax

Practice location:
  • Phone: 919-232-5021
  • Fax: 919-232-5021
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: