Healthcare Provider Details

I. General information

NPI: 1811822208
Provider Name (Legal Business Name): SELITA REYNOSO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 C CT
ASHTABULA OH
44004-4577
US

IV. Provider business mailing address

12557 RAVENWOOD DR
CHARDON OH
44024-9009
US

V. Phone/Fax

Practice location:
  • Phone: 440-998-4210
  • Fax: 440-998-6489
Mailing address:
  • Phone: 440-285-3568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.186485
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: