Provider Demographics
NPI:1447974373
Name:REYNOSO, ILYANA AMALIA (NP)
Entity type:Individual
Prefix:
First Name:ILYANA
Middle Name:AMALIA
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 YELLOW RIVER DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8700
Mailing Address - Country:US
Mailing Address - Phone:646-496-5306
Mailing Address - Fax:
Practice Address - Street 1:455 GRAYSON HWY STE 300
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-6387
Practice Address - Country:US
Practice Address - Phone:770-339-4283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN244021363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily