Healthcare Provider Details

I. General information

NPI: 1043076037
Provider Name (Legal Business Name): AMBER FAGIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2134 NICHOLASVILLE RD STE 12
LEXINGTON KY
40503-4050
US

IV. Provider business mailing address

3301 ORCHARD GRASS RD
LEXINGTON KY
40509-8642
US

V. Phone/Fax

Practice location:
  • Phone: 859-907-8925
  • Fax:
Mailing address:
  • Phone: 859-907-8925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number252357
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: