Healthcare Provider Details

I. General information

NPI: 1114653797
Provider Name (Legal Business Name): DEVONNE FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 WAVERLY AVE
TOLEDO OH
43607-3836
US

IV. Provider business mailing address

636 WAVERLY AVE
TOLEDO OH
43607-3836
US

V. Phone/Fax

Practice location:
  • Phone: 419-214-9302
  • Fax:
Mailing address:
  • Phone: 419-214-9302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: