Healthcare Provider Details

I. General information

NPI: 1649668674
Provider Name (Legal Business Name): ABAGAEL JEANNE FAGAN WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2014
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date: 09/09/2025
Reactivation Date: 09/25/2025

III. Provider practice location address

101 NICOLLS ROAD HSC 9, ROOM 020
STONY BROOK NY
11794-8091
US

IV. Provider business mailing address

4 LAYTON LN
CENTEREACH NY
11720-3631
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-3987
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF421892
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: