Provider Demographics
NPI:1083265995
Name:FAGARAGAN, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:FAGARAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 BEVILLE RD STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1970
Mailing Address - Country:US
Mailing Address - Phone:386-871-4781
Mailing Address - Fax:386-761-5868
Practice Address - Street 1:687 BEVILLE RD STE A
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1970
Practice Address - Country:US
Practice Address - Phone:386-871-4781
Practice Address - Fax:386-761-5868
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104854300Medicaid