Healthcare Provider Details

I. General information

NPI: 1912234972
Provider Name (Legal Business Name): MAUREEN BERNADETTE FAGAN RNP/MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6110
US

IV. Provider business mailing address

3 CANDLESTICK LN
FRAMINGHAM MA
01702-5537
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-4215
  • Fax: 617-975-0825
Mailing address:
  • Phone: 617-943-2135
  • Fax: 617-975-0825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number158764
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number158764
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: