MEDICARE: KATHLEEN F. REYNOLDS RN

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	163W00000X	Registered Nurse	102660-030	WI

General Provider Information

NPI Number	:	1952541195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN F. REYNOLDS RN

Provider Business Mailing Address
First Line	:	1211 DIVISION ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54303-3030
Country	:	US
Telephone Number	:	920-499-7142
Fax Number	:

Provider Business Practice Location Address
First Line	:	1211 DIVISION ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54303-3030
Country	:	US
Telephone Number	:	920-499-7142
Fax Number	:

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

Provider Enumeration Date	:	02/28/2009
Last Update Date	:	02/28/2009

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