Basic Information
| Provider Information | |||||||||
| NPI: | 1144297490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAKNER | ||||||||
| FirstName: | REGINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 FAIRFIELD AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182264892 | ||||||||
| FaxNumber: | 3182274927 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 FAIRFIELD AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182264892 | ||||||||
| FaxNumber: | 3182274927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 23952 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1667145 | 05 | LA | MEDICAID |