Healthcare Provider Details

I. General information

NPI: 1851545438
Provider Name (Legal Business Name): MS. KELSEY HEATHER FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-2301 OLD FT WEAVER RD
EWA BEACH HI
96706-3602
US

IV. Provider business mailing address

1327 KEOLU DR
KAILUA HI
96734-4113
US

V. Phone/Fax

Practice location:
  • Phone: 808-671-8511
  • Fax: 808-677-2525
Mailing address:
  • Phone: 360-961-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: