Provider Demographics
NPI:1801889498
Name:REYNOLDS, SUSAN MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:CHANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1 SAINT JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-9017
Mailing Address - Country:US
Mailing Address - Phone:641-437-3000
Mailing Address - Fax:641-437-3403
Practice Address - Street 1:522 N HANCOCK ST
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-4231
Practice Address - Country:US
Practice Address - Phone:641-683-0800
Practice Address - Fax:641-683-0801
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT36832363LF0000X
IAA074307363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1801889498Medicaid
ID1801889498Medicaid
WA1801889498Medicaid
MT0000374761OtherBCBSMT
ID1801889498Medicaid
WA1801889498Medicaid
WA1801889498Medicaid