Provider Demographics
NPI:1780569137
Name:REYNOLDS, MOLLIE
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E ABBEY PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6029
Mailing Address - Country:US
Mailing Address - Phone:601-750-6687
Mailing Address - Fax:601-750-6687
Practice Address - Street 1:614 E ABBEY PL
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6029
Practice Address - Country:US
Practice Address - Phone:601-750-6687
Practice Address - Fax:601-750-6687
Is Sole Proprietor?:No
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS907663363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily