1972098697 NPI number — COURTNEY FAGAN REGISTERED NURSE

Table of content: COURTNEY FAGAN REGISTERED NURSE (NPI 1972098697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972098697 NPI number — COURTNEY FAGAN REGISTERED NURSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAGAN
Provider First Name:
COURTNEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
REGISTERED NURSE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972098697
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6316 37TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENOSHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53142-3364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-752-7240
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3805 SPRING STREET
Provider Second Line Business Practice Location Address:
BLDG A - SUITE 311
Provider Business Practice Location Address City Name:
RACINE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53405-1600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-687-6345
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WD0400X , with the licence number:  184877-30 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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