Healthcare Provider Details

I. General information

NPI: 1093929713
Provider Name (Legal Business Name): MARY FAGO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 BEECH ST TEEN CLINIC
HOLYOKE MA
01040-3968
US

IV. Provider business mailing address

66 ROE AVE
NORTHAMPTON MA
01060-1636
US

V. Phone/Fax

Practice location:
  • Phone: 413-534-2033
  • Fax:
Mailing address:
  • Phone: 413-584-1732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number109181
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: