Healthcare Provider Details

I. General information

NPI: 1174306948
Provider Name (Legal Business Name): KIMBERLY ANN FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 3RD AVE W
HIBBING MN
55746-1512
US

IV. Provider business mailing address

2202 3RD AVE W
HIBBING MN
55746-1512
US

V. Phone/Fax

Practice location:
  • Phone: 218-393-3584
  • Fax:
Mailing address:
  • Phone: 218-393-3584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: