Provider Demographics
NPI:1356509129
Name:FACKLAM, ARNOLD WILLIAM III (APRN)
Entity Type:Individual
Prefix:MR
First Name:ARNOLD
Middle Name:WILLIAM
Last Name:FACKLAM
Suffix:III
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-8260
Mailing Address - Fax:239-343-8261
Practice Address - Street 1:5216 CLAYTON COURT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907
Practice Address - Country:US
Practice Address - Phone:239-343-8260
Practice Address - Fax:239-343-8261
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN325609363LF0000X
FLAPRN9420829363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016126500Medicaid
NYJ400001352OtherMEDICARE PTAN OBS ASSOCIATES U OF R