MEDICARE: VAN THUY FAGERT CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	SP016559	PA
2	363LA2200X	Adult Health Nurse Practitioner	APRN.CNP.0029226	OH

General Provider Information

NPI Number	:	1578011409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VAN THUY FAGERT CRNP

Provider Business Mailing Address
First Line	:	8522 CREEKSIDE DR
Second Line	:
City	:	NORTHFIELD
State	:	OH
Zip	:	44067-1877
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9500 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44195-4738
Country	:	US
Telephone Number	:	216-636-5860
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2016
Last Update Date	:	02/01/2022

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