Provider Demographics
NPI:1578373668
Name:REYNOLDS, LISA MARIE (AGPCNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 J CLYDE MORRIS BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1929
Mailing Address - Country:US
Mailing Address - Phone:757-329-1975
Mailing Address - Fax:
Practice Address - Street 1:500 J CLYDE MORRIS BLVD STE 500
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-873-1374
Practice Address - Fax:757-873-1612
Is Sole Proprietor?:No
Enumeration Date:2025-01-10
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024192287363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner