MEDICARE: MRS. REBECCA LOUISE REYNOLDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN099497	OH

General Provider Information

NPI Number	:	1356553580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA LOUISE REYNOLDS

Provider Business Mailing Address
First Line	:	3225 MANZANITA DRIVE
Second Line	:
City	:	WEST SALEM
State	:	OH
Zip	:	44287
Country	:	US
Telephone Number	:	419-945-2318
Fax Number	:	419-945-2318

Provider Business Practice Location Address
First Line	:	3225 MANZANITA DRIVE
Second Line	:
City	:	WEST SALEM
State	:	OH
Zip	:	44287
Country	:	US
Telephone Number	:	419-945-2318
Fax Number	:	419-945-2318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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