Healthcare Provider Details

I. General information

NPI: 1194744755
Provider Name (Legal Business Name): JUDITH FAGEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 W BROWN RD
MESA AZ
85201-3227
US

IV. Provider business mailing address

3255 E ELWOOD ST #110
PHOENIX AZ
85034-7256
US

V. Phone/Fax

Practice location:
  • Phone: 480-344-2007
  • Fax:
Mailing address:
  • Phone: 602-470-5043
  • Fax: 602-470-5064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: