Healthcare Provider Details

I. General information

NPI: 1437170800
Provider Name (Legal Business Name): CONNIE MARION REYNOLDS APRN BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 FOREST DR SUITE 5
GRAY TN
37615
US

IV. Provider business mailing address

2102 FOREST DR SUITE 5
GRAY TN
37615
US

V. Phone/Fax

Practice location:
  • Phone: 423-794-6595
  • Fax: 423-477-0310
Mailing address:
  • Phone: 423-794-6595
  • Fax: 423-477-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12126
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN0000012126
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: