Provider Demographics
NPI:1013111517
Name:PRINCE, REGINA D (CRNA)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:D
Last Name:PRINCE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:D
Other - Last Name:HARKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 1351
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-1351
Mailing Address - Country:US
Mailing Address - Phone:800-235-1415
Mailing Address - Fax:913-234-1108
Practice Address - Street 1:1808 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2724
Practice Address - Country:US
Practice Address - Phone:479-968-2841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCTP000048367500000X
ARC02671367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5A423OtherBCBS
AR165275001Medicaid
AR771053701OtherAR BREASTCARE
ARP00603893OtherRR MEDICARE FOR GROUP CC5970
AR5A4237607Medicare PIN