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: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 RACETRACK RD NW STE 100C
FORT WALTON BEACH FL
32547-1796
US

IV. Provider business mailing address

320 RACETRACK RD NW STE 100C
FORT WALTON BEACH FL
32547-1796
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-0883
  • Fax:
Mailing address:
  • Phone: 850-863-0883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1046195
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN11031708
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: