Healthcare Provider Details

I. General information

NPI: 1326494782
Provider Name (Legal Business Name): AMY FAGAN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 CONANT ST STE 3
BEVERLY MA
01915-1659
US

IV. Provider business mailing address

152 CONANT ST STE 3
BEVERLY MA
01915-1659
US

V. Phone/Fax

Practice location:
  • Phone: 978-236-1300
  • Fax:
Mailing address:
  • Phone: 978-236-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN234050
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: