MEDICARE: MADDIE ELIZABETH 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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1669366605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADDIE ELIZABETH REYNOLDS

Provider Business Mailing Address
First Line	:	11409 WALLACE AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-1318
Country	:	US
Telephone Number	:	405-627-3002
Fax Number	:

Provider Business Practice Location Address
First Line	:	11409 WALLACE AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-1318
Country	:	US
Telephone Number	:	405-627-3002
Fax Number	:

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

Provider Enumeration Date	:	06/04/2025
Last Update Date	:	06/04/2025

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