Healthcare Provider Details

I. General information

NPI: 1104246545
Provider Name (Legal Business Name): SHANNON RENEE FAULKINBERRY MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON RENEE WELLS MD, MPH

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 BERT KOUNS INDUSTRIAL LOOP
SHREVEPORT LA
71118-3119
US

IV. Provider business mailing address

2510 BERT KOUNS INDUSTRIAL LOOP
SHREVEPORT LA
71118-3119
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5665
  • Fax: 318-212-5698
Mailing address:
  • Phone: 318-212-5665
  • Fax: 318-212-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberME144400
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: