Healthcare Provider Details

I. General information

NPI: 1356911671
Provider Name (Legal Business Name): KATERINA FAGAN ACNPC-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 BROOKMEADE DR
CRESTVIEW FL
32539-7304
US

IV. Provider business mailing address

PO BOX 1027
NICEVILLE FL
32588-1027
US

V. Phone/Fax

Practice location:
  • Phone: 850-605-0550
  • Fax: 850-605-0440
Mailing address:
  • Phone: 850-605-0550
  • Fax: 850-605-0440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number11031708
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN11031708
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1046195
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: