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General NPI Number Information
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NPI Number | 1164084455
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Entity Type | Individual
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Provider Name | CAMILLE FAGAN
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Gender | Female
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Dates
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Enumeration Date | 07/08/2019
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Last Update Date | 10/01/2024
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Provider Practice Location Address
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Address Line | 11960 WESTLINE INDUSTRIAL DR STE 201
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City | SAINT LOUIS
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State | MO
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Zip | 63146-3209
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Country | US
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Telephone | 866-433-9555
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Fax |
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Provider Business Mailing Address
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Address Line | 27130 HUNT DR
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City | WRIGHT CITY
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State | MO
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Zip | 63390-4419
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Country | US
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Telephone | 314-446-9041
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XG0600X
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Taxonomy Name | Gerontology Occupational Therapist
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License Number | 2019017425
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License Number State | MO
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