Healthcare Provider Details

I. General information

NPI: 1942842398
Provider Name (Legal Business Name): MCKENZIE CHRISTINE FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SEVILLE ST
PHILADELPHIA PA
19127-1811
US

IV. Provider business mailing address

105 SEVILLE ST
PHILADELPHIA PA
19127-1811
US

V. Phone/Fax

Practice location:
  • Phone: 724-372-9269
  • Fax:
Mailing address:
  • Phone: 724-372-9269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255R0406X
TaxonomyBlind Rehabilitation Specialist/Technologist
License Number9462063
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: