Provider Demographics
NPI:1386974517
Name:FAGAN, KATHLEEN ANNE (DNSC, RN, BC, APN)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANNE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:DNSC, RN, BC, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 DEERFIELD TER
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-2853
Mailing Address - Country:US
Mailing Address - Phone:210-694-7920
Mailing Address - Fax:201-934-6691
Practice Address - Street 1:241 MOORE ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-7533
Practice Address - Country:US
Practice Address - Phone:201-342-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN09492700363LW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology