MEDICARE: STEPHANIE LYNN FAGIN P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172M00000X	Mechanotherapist	329509-2401	UT
2	225100000X	Physical Therapist	329509	UT

General Provider Information

NPI Number	:	1679876437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE LYNN FAGIN P.T.

Provider Business Mailing Address
First Line	:	1112 BURNT FORK RD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1756
Country	:	US
Telephone Number	:	801-598-8777
Fax Number	:

Provider Business Practice Location Address
First Line	:	1112 BURNT FORK RD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1756
Country	:	US
Telephone Number	:	801-598-8777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2010
Last Update Date	:	10/25/2021

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