Healthcare Provider Details

I. General information

NPI: 1861356719
Provider Name (Legal Business Name): MRS. ANDREA MICHELE REYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 E 24TH ST
TISHOMINGO OK
73460-3214
US

IV. Provider business mailing address

32790 STATE HIGHWAY 99 S
STONEWALL OK
74871-6128
US

V. Phone/Fax

Practice location:
  • Phone: 580-235-0274
  • Fax:
Mailing address:
  • Phone: 580-272-4277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: