Healthcare Provider Details

I. General information

NPI: 1205878428
Provider Name (Legal Business Name): LINDA FAGAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 E OGLETHORPE HWY
HINESVILLE GA
31313-1200
US

IV. Provider business mailing address

1113 E OGLETHORPE HWY
HINESVILLE GA
31313-1200
US

V. Phone/Fax

Practice location:
  • Phone: 912-876-2173
  • Fax: 912-368-8033
Mailing address:
  • Phone: 912-876-2173
  • Fax: 912-368-8033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN101672
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: