Provider Demographics
NPI:1962914366
Name:REYNOLDS, ISHARON BENYETTE (NP-C)
Entity type:Individual
Prefix:MS
First Name:ISHARON
Middle Name:BENYETTE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 S GREYFRIAR ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48217-1072
Mailing Address - Country:US
Mailing Address - Phone:313-629-9330
Mailing Address - Fax:
Practice Address - Street 1:2111 WOODWARD AVE STE 1200
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-3415
Practice Address - Country:US
Practice Address - Phone:313-488-4332
Practice Address - Fax:313-488-4332
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704361588363LF0000X
OHAPRN.CNP.023310363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty