Provider Demographics
NPI:1164559332
Name:FAGERBERG, KAYLA (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:
Last Name:FAGERBERG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:696 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1842
Mailing Address - Country:US
Mailing Address - Phone:781-331-3820
Mailing Address - Fax:781-331-1076
Practice Address - Street 1:696 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1842
Practice Address - Country:US
Practice Address - Phone:781-331-3820
Practice Address - Fax:781-331-1076
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA118198367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANA050802Medicare PIN