Provider Demographics
NPI:1194842849
Name:FAGAN, MELISSA MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3178
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-3178
Mailing Address - Country:US
Mailing Address - Phone:319-398-1583
Mailing Address - Fax:319-399-2085
Practice Address - Street 1:202 10TH STREET SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2404
Practice Address - Country:US
Practice Address - Phone:319-398-1545
Practice Address - Fax:319-399-2039
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA080649363LC1500X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP10570Medicare UPIN
IAI19828Medicare PIN