Provider Demographics
NPI:1922862739
Name:REYNOSO, MAKALA PAIGE
Entity type:Individual
Prefix:
First Name:MAKALA
Middle Name:PAIGE
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7125 NEW SANGER AVE STE 516
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-4054
Mailing Address - Country:US
Mailing Address - Phone:254-752-9638
Mailing Address - Fax:
Practice Address - Street 1:7125 NEW SANGER AVE STE 516
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-4054
Practice Address - Country:US
Practice Address - Phone:254-752-9638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1153306363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily