=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821766155
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALLISON B REYNOLDS APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2021
-----------------------------------------------------
Last Update Date | 12/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4123 DUTCHMANS LN STE 102
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40207-4718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-559-1670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3623 E LOCUST CIR
-----------------------------------------------------
City | PROSPECT
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40059-9020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-599-1184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 3016451
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 3016451
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------