Healthcare Provider Details

I. General information

NPI: 1568188100
Provider Name (Legal Business Name): VIRGINIA SUE FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 RESTER RD
PERKINSTON MS
39573-4947
US

IV. Provider business mailing address

29 RESTER RD
PERKINSTON MS
39573-4947
US

V. Phone/Fax

Practice location:
  • Phone: 228-343-3105
  • Fax:
Mailing address:
  • Phone: 228-343-3105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: