Basic Information
| Provider Information | |||||||||
| NPI: | 1477598498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRAVEN | ||||||||
| OtherFirstName: | PAMELA | ||||||||
| OtherMiddleName: | F | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5627 NW 86TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | JOHNSTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501311738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152700303 | ||||||||
| FaxNumber: | 5152700160 | ||||||||
| Practice Location | |||||||||
| Address1: | 5627 NW 86TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | JOHNSTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501311738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152700303 | ||||||||
| FaxNumber: | 5152700160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 01770 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.