1306181748 NPI number — MRS. KELLIE RENEE REYNOLDS TLLP

Table of content: MRS. KELLIE RENEE REYNOLDS TLLP (NPI 1306181748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306181748 NPI number — MRS. KELLIE RENEE REYNOLDS TLLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
KELLIE
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
TLLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDMONDS
Provider Other First Name:
KELLIE
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
TLLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306181748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5380 HOLIDAY TERRACE
Provider Second Line Business Mailing Address:
SUITE 32
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-459-1512
Provider Business Mailing Address Fax Number:
269-459-1514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5380 HOLIDAY TERRACE
Provider Second Line Business Practice Location Address:
SUITE 32
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-459-1512
Provider Business Practice Location Address Fax Number:
269-459-1514
Provider Enumeration Date:
12/11/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  6301014983 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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