Healthcare Provider Details

I. General information

NPI: 1760365530
Provider Name (Legal Business Name): ANNALIESA FANGUY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 E TEXAS ST
BOSSIER CITY LA
71111-6906
US

IV. Provider business mailing address

611 E DOUGLAS RD STE 407
MISHAWAKA IN
46545-1468
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-1313
  • Fax:
Mailing address:
  • Phone: 574-335-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number348260
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: