Basic Information
| Provider Information | |||||||||
| NPI: | 1083211882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 299 | ||||||||
| Address2: | |||||||||
| City: | HOXIE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724330299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708861333 | ||||||||
| FaxNumber: | 8708861334 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 E 8TH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726534423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707015141 | ||||||||
| FaxNumber: | 8707015177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2020 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.