Healthcare Provider Details

I. General information

NPI: 1275067563
Provider Name (Legal Business Name): JUDITH FAGER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5105 W GOLDLEAF CIR
LOS ANGELES CA
90056-1269
US

IV. Provider business mailing address

3619 S BARRINGTON AVE
LOS ANGELES CA
90066-2831
US

V. Phone/Fax

Practice location:
  • Phone: 310-729-6201
  • Fax:
Mailing address:
  • Phone: 310-729-6201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number441623
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number441623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: