Healthcare Provider Details

I. General information

NPI: 1003199456
Provider Name (Legal Business Name): BROWNIE FAGAN RN BSN CMSRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 06/12/2021
Certification Date: 06/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 ISELIN AVE
BRONX NY
10471-2915
US

IV. Provider business mailing address

5050 ISELIN AVE
BRONX NY
10471-2915
US

V. Phone/Fax

Practice location:
  • Phone: 718-549-6700
  • Fax:
Mailing address:
  • Phone: 718-549-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number704102-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: