Provider Demographics
NPI:1730933946
Name:REYNOLDS, AVUSE ANTIONETTE
Entity type:Individual
Prefix:MRS
First Name:AVUSE
Middle Name:ANTIONETTE
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 1:11383 PEPPER LN
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-7440
Mailing Address - Country:US
Mailing Address - Phone:951-703-9722
Mailing Address - Fax:
Practice Address - Street 1:CORONA-RINCON
Practice Address - Street 2:255 E. RINCON STREET
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879
Practice Address - Country:US
Practice Address - Phone:951-817-5328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30248167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician