=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477137255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RHIANNON ANGELINA REYNOLDS BS, MS, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2021
-----------------------------------------------------
Last Update Date | 05/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 OVERTON AVE
-----------------------------------------------------
City | SAYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11782-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-660-5897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 OVERTON AVE
-----------------------------------------------------
City | SAYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11782-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-660-5897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 003126
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------