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: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 ASHELAND AVE
ASHEVILLE NC
28801-4021
US

IV. Provider business mailing address

200 OLDE EASTWOOD VILLAGE BLVD APARTMENT 213
ASHEVILLE NC
28803-1680
US

V. Phone/Fax

Practice location:
  • Phone: 828-254-2700
  • Fax:
Mailing address:
  • Phone: 585-259-5272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF400995-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF381648-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number229768
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: