1104246545 NPI number — SHANNON RENEE FAULKINBERRY MD, MPH

Table of content: SHANNON RENEE FAULKINBERRY MD, MPH (NPI 1104246545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104246545 NPI number — SHANNON RENEE FAULKINBERRY MD, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAULKINBERRY
Provider First Name:
SHANNON
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, MPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WELLS
Provider Other First Name:
SHANNON
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD, MPH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104246545
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2510 BERT KOUNS INDUSTRIAL LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71118-3119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-212-5665
Provider Business Mailing Address Fax Number:
318-212-5698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2510 BERT KOUNS INDUSTRIAL LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118-3119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-212-5665
Provider Business Practice Location Address Fax Number:
318-212-5698
Provider Enumeration Date:
04/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0203X , with the licence number:  ME144400 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 106540900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com