Healthcare Provider Details

I. General information

NPI: 1801276118
Provider Name (Legal Business Name): JACQUELINE FAGONI NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 01/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 HYLAN BLVD
STATEN ISLAND NY
10305-1902
US

IV. Provider business mailing address

1361 HYLAN BLVD
STATEN ISLAND NY
10305-1902
US

V. Phone/Fax

Practice location:
  • Phone: 888-771-1874
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00567900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number33339339
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: