Healthcare Provider Details

I. General information

NPI: 1144337536
Provider Name (Legal Business Name): KELLY C FAGUNDES PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 CANTERBURY LN
SISTER BAY WI
54234-5602
US

IV. Provider business mailing address

323 S 18TH AVE
STURGEON BAY WI
54235-1401
US

V. Phone/Fax

Practice location:
  • Phone: 920-854-4111
  • Fax:
Mailing address:
  • Phone: 920-746-0410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: