Healthcare Provider Details

I. General information

NPI: 1124214788
Provider Name (Legal Business Name): KATHLEEN FAGERLAND CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 2ND AVE N
TWIN FALLS ID
83301-6158
US

IV. Provider business mailing address

3668 N HARBOR LN
BOISE ID
83703-6914
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-9955
  • Fax: 208-734-9966
Mailing address:
  • Phone: 208-376-9300
  • Fax: 208-376-9444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SW0102X
TaxonomyWomen's Health Clinical Nurse Specialist
License NumberCNM-41A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: