Basic Information
| Provider Information | |||||||||
| NPI: | 1063838654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | LORA | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | SUITE 313 | ||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762583780 | ||||||||
| FaxNumber: | 2762583776 | ||||||||
| Practice Location | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | SUITE 313 | ||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762583780 | ||||||||
| FaxNumber: | 2762583776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2014 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024171491 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1063838654 | 05 | VA | MEDICAID | P01502220 | 01 | VA | RAILROAD MEDICARE | OTHER |