Healthcare Provider Details

I. General information

NPI: 1851081830
Provider Name (Legal Business Name): ANGELA MARIE FAGNANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 W 800 S
ROOSEVELT UT
84066-3707
US

IV. Provider business mailing address

1140 W 500 S STE 9
VERNAL UT
84078-2912
US

V. Phone/Fax

Practice location:
  • Phone: 435-725-6300
  • Fax: 435-725-6325
Mailing address:
  • Phone: 435-789-6300
  • Fax: 435-789-6357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: