Healthcare Provider Details

I. General information

NPI: 1699263616
Provider Name (Legal Business Name): MOLLY FAGEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4842 SW ARCHER RD
GAINESVILLE FL
32608-3813
US

IV. Provider business mailing address

16686 NW 194TH TER
HIGH SPRINGS FL
32643-8182
US

V. Phone/Fax

Practice location:
  • Phone: 352-376-8821
  • Fax: 352-382-7781
Mailing address:
  • Phone: 352-382-7214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT31978
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: