Healthcare Provider Details

I. General information

NPI: 1164559332
Provider Name (Legal Business Name): KAYLA FAGERBERG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

696 MAIN ST
WEYMOUTH MA
02190-1842
US

IV. Provider business mailing address

696 MAIN ST
WEYMOUTH MA
02190-1842
US

V. Phone/Fax

Practice location:
  • Phone: 781-331-3820
  • Fax: 781-331-1076
Mailing address:
  • Phone: 781-331-3820
  • Fax: 781-331-1076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number118198
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: