Healthcare Provider Details

I. General information

NPI: 1134036015
Provider Name (Legal Business Name): ASHLEY FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY MOLL

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 FLINTSHIRE LN
LAKE SAINT LOUIS MO
63367-1949
US

IV. Provider business mailing address

1328 FLINTSHIRE LN
LAKE SAINT LOUIS MO
63367-1949
US

V. Phone/Fax

Practice location:
  • Phone: 573-768-6345
  • Fax:
Mailing address:
  • Phone: 573-768-6345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number2017021347
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: