Provider Demographics
NPI:1194201814
Name:FINICUM, REGINA HEATON
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:HEATON
Last Name:FINICUM
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:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:AZ
Mailing Address - Zip Code:86022-0528
Mailing Address - Country:US
Mailing Address - Phone:435-689-9787
Mailing Address - Fax:
Practice Address - Street 1:2800 N. 50 E.
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:AZ
Practice Address - Zip Code:86022
Practice Address - Country:US
Practice Address - Phone:435-689-9787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ368267253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency