Provider Demographics
NPI:1124214788
Name:FAGERLAND, KATHLEEN (CNM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:FAGERLAND
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3668 N HARBOR LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-6914
Mailing Address - Country:US
Mailing Address - Phone:208-376-9300
Mailing Address - Fax:208-376-9444
Practice Address - Street 1:200 2ND AVE N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6158
Practice Address - Country:US
Practice Address - Phone:208-734-9955
Practice Address - Fax:208-734-9966
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNM-41A364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health