Healthcare Provider Details

I. General information

NPI: 1790192698
Provider Name (Legal Business Name): PAMELA FAGEN REGISTERED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2014
Last Update Date: 07/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E DEVON AVE STE 309
DES PLAINES IL
60018-4505
US

IV. Provider business mailing address

8325 S HERMITAGE AVE
CHICAGO IL
60620-4630
US

V. Phone/Fax

Practice location:
  • Phone: 847-708-4929
  • Fax:
Mailing address:
  • Phone: 949-394-1064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164003018
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: