Healthcare Provider Details

I. General information

NPI: 1417773565
Provider Name (Legal Business Name): MS. ANGELA M FAGANS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14164 RUTHERFORD ST
DETROIT MI
48227-1844
US

IV. Provider business mailing address

14164 RUTHERFORD ST
DETROIT MI
48227-1844
US

V. Phone/Fax

Practice location:
  • Phone: 734-469-8820
  • Fax:
Mailing address:
  • Phone: 734-469-8820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: