Provider Demographics
NPI:1437031986
Name:REYNOLDS, ELISA (FNP-BC)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 KORU ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-5316
Mailing Address - Country:US
Mailing Address - Phone:530-414-1564
Mailing Address - Fax:
Practice Address - Street 1:3501 PALMER DR STE 201
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8276
Practice Address - Country:US
Practice Address - Phone:530-672-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95036332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily