Healthcare Provider Details

I. General information

NPI: 1881041572
Provider Name (Legal Business Name): KATHLEEN ANN FAGAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 AUBURN RD
CONCORD TOWNSHIP OH
44077-9602
US

IV. Provider business mailing address

7616 BRAINARD CT
MENTOR OH
44060-3910
US

V. Phone/Fax

Practice location:
  • Phone: 440-358-0400
  • Fax:
Mailing address:
  • Phone: 440-255-1735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 184028
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: