Healthcare Provider Details

I. General information

NPI: 1396926945
Provider Name (Legal Business Name): LISA DIANE REYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2007
Last Update Date: 12/14/2019
Certification Date: 12/14/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 40TH ST
LUBBOCK TX
79404-2746
US

IV. Provider business mailing address

301 40TH ST
LUBBOCK TX
79404-2746
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-9355
  • Fax: 806-743-9363
Mailing address:
  • Phone: 806-743-9355
  • Fax: 806-743-9363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number658247
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP117413
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: