Provider Demographics
NPI:1437636511
Name:REYNOLDS, LAURA JO (RN)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JO
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7319 KINNE RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-9358
Mailing Address - Country:US
Mailing Address - Phone:716-523-5100
Mailing Address - Fax:
Practice Address - Street 1:25 CHATEAU TER
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14226-3927
Practice Address - Country:US
Practice Address - Phone:716-839-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY636782163W00000X
NYF352911-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse