Healthcare Provider Details

I. General information

NPI: 1194122671
Provider Name (Legal Business Name): CRYSTAL LYNN FAGERSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL LYNN NAGARUK

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 PUNGUK STREET
GOLOVIN AK
99762
US

IV. Provider business mailing address

39 PUNGUK STREET
GOLOVIN AK
99762
US

V. Phone/Fax

Practice location:
  • Phone: 907-779-3311
  • Fax: 907-779-3312
Mailing address:
  • Phone: 907-779-3311
  • Fax: 907-779-3312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: