=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861236689
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADISON FAGAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2024
-----------------------------------------------------
Last Update Date | 08/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 COWLES CLINIC WAY STE M-200
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30642-4541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-454-0159
-----------------------------------------------------
Fax | 706-454-3059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 517 GREAT OAKS DR STE 102
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30655-8229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-635-3677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN287732
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------