Healthcare Provider Details

I. General information

NPI: 1578011409
Provider Name (Legal Business Name): VAN THUY FAGERT CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-4738
US

IV. Provider business mailing address

8522 CREEKSIDE DR
NORTHFIELD OH
44067-1877
US

V. Phone/Fax

Practice location:
  • Phone: 216-636-5860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP016559
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN.CNP.0029226
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: