Healthcare Provider Details

I. General information

NPI: 1194209692
Provider Name (Legal Business Name): COURTNEY REYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1088 W BALTIMORE PIKE STE 2500
MEDIA PA
19063-5166
US

IV. Provider business mailing address

3803 W CHESTER PIKE STE 160
NEWTOWN SQUARE PA
19073-2336
US

V. Phone/Fax

Practice location:
  • Phone: 484-227-8800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP020138
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0001199
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP020138
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL1-0038092
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: