Healthcare Provider Details

I. General information

NPI: 1922592153
Provider Name (Legal Business Name): HEATHER S FAGNANT MS, MPH, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 CAMBRIDGE ST
BRIGHTON MA
02135-2907
US

IV. Provider business mailing address

531 WASHINGTON ST APT 3
BROOKLINE MA
02446-4567
US

V. Phone/Fax

Practice location:
  • Phone: 617-562-7775
  • Fax:
Mailing address:
  • Phone: 401-447-2786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3418
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: