Provider Demographics
NPI:1730733429
Name:FACKLER, LAUREN MARIE
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARIE
Last Name:FACKLER
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 1:1060 SHENANDOAH ST APT A
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22802-5447
Mailing Address - Country:US
Mailing Address - Phone:540-391-1091
Mailing Address - Fax:
Practice Address - Street 1:25 MYERS CORNER DR
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-6342
Practice Address - Country:US
Practice Address - Phone:540-688-2646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-006810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant