Healthcare Provider Details

I. General information

NPI: 1114463502
Provider Name (Legal Business Name): KAREN FAGAN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 02/20/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ALFRED ST
MICHIGAN CITY IN
46360
US

IV. Provider business mailing address

710 FRANKLIN ST STE 200
MICHIGAN CITY IN
46360-3564
US

V. Phone/Fax

Practice location:
  • Phone: 815-773-7827
  • Fax:
Mailing address:
  • Phone: 219-872-6200
  • Fax: 219-879-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209015643
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: