Healthcare Provider Details

I. General information

NPI: 1003064957
Provider Name (Legal Business Name): LINDA SUE FAGAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 SHERIDAN RD
PORTSMOUTH OH
45662-2359
US

IV. Provider business mailing address

3525 SHERIDAN RD
PORTSMOUTH OH
45662-2359
US

V. Phone/Fax

Practice location:
  • Phone: 740-353-8716
  • Fax: 740-353-8716
Mailing address:
  • Phone: 740-353-8716
  • Fax: 740-353-8716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number320356
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: