Healthcare Provider Details

I. General information

NPI: 1346927688
Provider Name (Legal Business Name): MICHELLE FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W MARKET ST
AKRON OH
44303-1411
US

IV. Provider business mailing address

611 W MARKET ST
AKRON OH
44303-1411
US

V. Phone/Fax

Practice location:
  • Phone: 330-996-4600
  • Fax: 330-564-9296
Mailing address:
  • Phone: 330-996-4600
  • Fax: 330-564-9296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberRA163548
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: