Healthcare Provider Details

I. General information

NPI: 1154687432
Provider Name (Legal Business Name): KIMBERLY HOLLEY REAGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MORRIS CIR
HOMER LA
71040-2109
US

IV. Provider business mailing address

104 MORRIS CIR
HOMER LA
71040-2109
US

V. Phone/Fax

Practice location:
  • Phone: 318-927-6777
  • Fax: 318-927-6714
Mailing address:
  • Phone: 318-927-6777
  • Fax: 318-927-6714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.207697
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: