Healthcare Provider Details

I. General information

NPI: 1861236689
Provider Name (Legal Business Name): MADISON FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 COWLES CLINIC WAY STE M-200
GREENSBORO GA
30642-4541
US

IV. Provider business mailing address

517 GREAT OAKS DR STE 102
MONROE GA
30655-8229
US

V. Phone/Fax

Practice location:
  • Phone: 706-454-0159
  • Fax: 706-454-3059
Mailing address:
  • Phone: 678-635-3677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN287732
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: