Healthcare Provider Details

I. General information

NPI: 1013167402
Provider Name (Legal Business Name): DEVONA L. FAGAN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 ADAMS BLVD
BOULDER CITY NV
89005-2235
US

IV. Provider business mailing address

895 ADAMS BLVD
BOULDER CITY NV
89005-2235
US

V. Phone/Fax

Practice location:
  • Phone: 702-293-0406
  • Fax: 702-293-0192
Mailing address:
  • Phone: 702-293-0406
  • Fax: 702-293-0192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberNP17793
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number17793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: