Basic Information
| Provider Information | |||||||||
| NPI: | 1609973221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | AUDREE | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3607 RIVERA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155337057 | ||||||||
| FaxNumber: | 9157571640 | ||||||||
| Practice Location | |||||||||
| Address1: | 4875 MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799041450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155337057 | ||||||||
| FaxNumber: | 9157571640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 12/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 419649 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 419649 | 01 | TX | RN & FNP LICENSE | OTHER | 103873902 | 05 | TX | MEDICAID |