Healthcare Provider Details

I. General information

NPI: 1134473069
Provider Name (Legal Business Name): KALI CHLORIN FAGNANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15022 TUFF RD
MANOR TX
78653-2344
US

IV. Provider business mailing address

15022 TUFF RD
MANOR TX
78653-2344
US

V. Phone/Fax

Practice location:
  • Phone: 307-254-0572
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number59803
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: