Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 020016257 | IL |
NPI | 1023597192 |
---|---|
Provider Name | Ms. Stephanie Marie Reynolds |
First Address | Darien, IL 60561-3693 |
Second Address | Lombard, IL 60148-6105 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2018 |
Last Update Date | 09/08/2018 |