Provider Demographics
NPI:1316900343
Name:BOGLE, REGINA C (NP)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:C
Last Name:BOGLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1508
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30015-1508
Mailing Address - Country:US
Mailing Address - Phone:470-444-1501
Mailing Address - Fax:470-444-1506
Practice Address - Street 1:1301 SIGMAN RD NE STE 180
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3924
Practice Address - Country:US
Practice Address - Phone:678-609-4913
Practice Address - Fax:678-609-4293
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN053871363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000762341Medicaid