Healthcare Provider Details

I. General information

NPI: 1386974517
Provider Name (Legal Business Name): KATHLEEN ANNE FAGAN DNSC, RN, BC, APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2010
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 MOORE ST
HACKENSACK NJ
07601-7533
US

IV. Provider business mailing address

188 DEERFIELD TER
MAHWAH NJ
07430-2853
US

V. Phone/Fax

Practice location:
  • Phone: 201-342-2478
  • Fax:
Mailing address:
  • Phone: 210-694-7920
  • Fax: 201-934-6691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number26NN09492700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number26NN09492700
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: