Healthcare Provider Details

I. General information

NPI: 1508928920
Provider Name (Legal Business Name): KELLY ANNE FAGAN NPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 PEACHTREE RD STE 110
ASHEVILLE NC
28803-0003
US

IV. Provider business mailing address

3835 N FREEWAY BLVD STE 100 APARTMENT 213
SACRAMENTO CA
95834-1954
US

V. Phone/Fax

Practice location:
  • Phone: 855-501-1004
  • Fax: 866-279-1549
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF381648-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5007235
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF400995-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: