Provider Demographics
NPI:1376509349
Name:HUMPHREY, REGINA RAE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:RAE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N DAVIS
Mailing Address - Street 2:#400
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012
Mailing Address - Country:US
Mailing Address - Phone:817-461-0199
Mailing Address - Fax:817-460-2153
Practice Address - Street 1:910 N DAVIS
Practice Address - Street 2:#400
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012
Practice Address - Country:US
Practice Address - Phone:817-461-0199
Practice Address - Fax:817-460-2153
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX502073363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
81N157OtherBCBS
81N157OtherBCBS