Basic Information
| Provider Information | |||||||||
| NPI: | 1851472120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | WYLENTHIA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | WYLENTHIA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12842 COUNTY HIGHWAY 27 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622632612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183144431 | ||||||||
| FaxNumber: | 6185375987 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 N WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | PINCKNEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622741034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183575935 | ||||||||
| FaxNumber: | 6183576336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 06/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056.008726 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.