Healthcare Provider Details

I. General information

NPI: 1104188945
Provider Name (Legal Business Name): ANGELA FAGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 MARC ST
STATEN ISLAND NY
10314-7442
US

IV. Provider business mailing address

31 MARC ST
STATEN ISLAND NY
10314-7442
US

V. Phone/Fax

Practice location:
  • Phone: 631-807-2821
  • Fax:
Mailing address:
  • Phone: 631-807-2821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number265776021
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: