Healthcare Provider Details

I. General information

NPI: 1295055242
Provider Name (Legal Business Name): SHERYL DIANE FAGAN A.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 VAN DYKE RD SUITE 200
LUTZ FL
33558-8005
US

IV. Provider business mailing address

PO BOX 10744
CLEARWATER FL
33757-8744
US

V. Phone/Fax

Practice location:
  • Phone: 813-264-6490
  • Fax: 813-443-8143
Mailing address:
  • Phone: 727-532-0002
  • Fax: 727-266-4928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP1662752
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: