Healthcare Provider Details

I. General information

NPI: 1700355088
Provider Name (Legal Business Name): NICOLE M. REYNOLDS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 DETROIT AVE
CLEVELAND OH
44102-2813
US

IV. Provider business mailing address

18697 BAGLEY RD
MIDDLEBURG HEIGHTS OH
44130-3417
US

V. Phone/Fax

Practice location:
  • Phone: 216-634-7400
  • Fax: 216-634-7483
Mailing address:
  • Phone: 440-816-2491
  • Fax: 440-816-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0029566
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.411828
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: