Healthcare Provider Details

I. General information

NPI: 1700395506
Provider Name (Legal Business Name): LAUREN KATHERINE FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 09/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HOWARD AVE
NEW HAVEN CT
06519-1369
US

IV. Provider business mailing address

9 MANISTEE LN
EAST ISLIP NY
11730-2607
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2467
  • Fax: 203-785-5936
Mailing address:
  • Phone: 631-220-0782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number000600
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: