Provider Demographics
NPI:1275067563
Name:FAGER, JUDITH (RN)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:FAGER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 S BARRINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-2831
Mailing Address - Country:US
Mailing Address - Phone:310-729-6201
Mailing Address - Fax:
Practice Address - Street 1:5105 W GOLDLEAF CIR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-1269
Practice Address - Country:US
Practice Address - Phone:310-729-6201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA441623163W00000X, 163WC1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163W00000XNursing Service ProvidersRegistered Nurse