Provider Demographics
NPI:1124619846
Name:FAGAN, REBECCA CARVER (APRN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:CARVER
Last Name:FAGAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5094
Mailing Address - Country:US
Mailing Address - Phone:321-268-6868
Mailing Address - Fax:321-267-2713
Practice Address - Street 1:250 HARRISON ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5094
Practice Address - Country:US
Practice Address - Phone:321-268-6868
Practice Address - Fax:321-267-2713
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11010912363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily