Healthcare Provider Details

I. General information

NPI: 1598238826
Provider Name (Legal Business Name): KENDRA FAGAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4009 NE 56TH TER
GLADSTONE MO
64119-2270
US

IV. Provider business mailing address

4009 NE 56TH TER
GLADSTONE MO
64119-2270
US

V. Phone/Fax

Practice location:
  • Phone: 816-277-4601
  • Fax:
Mailing address:
  • Phone: 816-201-3305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2010023959
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: