Healthcare Provider Details

I. General information

NPI: 1861371577
Provider Name (Legal Business Name): MOLLY ANN FAGAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6780 MAYFIELD RD
MAYFIELD HEIGHTS OH
44124-2203
US

IV. Provider business mailing address

10720 LOCUST GROVE DR
CHARDON OH
44024-8872
US

V. Phone/Fax

Practice location:
  • Phone: 440-312-4500
  • Fax:
Mailing address:
  • Phone: 440-537-5977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number2024089340
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: