Provider Demographics
NPI:1942009055
Name:REYNOLDS, MANDY LYNN
Entity type:Individual
Prefix:MS
First Name:MANDY
Middle Name:LYNN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MANDY
Other - Middle Name:LYNN
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4611 S 96TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-1242
Mailing Address - Country:US
Mailing Address - Phone:402-613-7198
Mailing Address - Fax:
Practice Address - Street 1:4823 N 118TH STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-2017
Practice Address - Country:US
Practice Address - Phone:402-598-6069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor