Provider Demographics
NPI:1942206693
Name:FACKLER, MARGARET (APRN)
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:
Last Name:FACKLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:FACKLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP
Mailing Address - Street 1:2215 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-1033
Mailing Address - Country:US
Mailing Address - Phone:502-774-8631
Mailing Address - Fax:502-776-8912
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-774-8631
Practice Address - Fax:502-776-8912
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3000508363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78009453Medicaid
KY000000199195OtherANTHEM
KYP71934Medicare UPIN