Healthcare Provider Details

I. General information

NPI: 1679258156
Provider Name (Legal Business Name): MONIQUE KERRY-JO FAGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 TULANE AVE # 8050
NEW ORLEANS LA
70112-2632
US

IV. Provider business mailing address

1430 TULANE AVE # 8050
NEW ORLEANS LA
70112-2632
US

V. Phone/Fax

Practice location:
  • Phone: 504-988-7809
  • Fax: 504-988-3971
Mailing address:
  • Phone: 504-988-7809
  • Fax: 504-988-3971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number337293
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: