Provider Demographics
NPI:1275836777
Name:FAGAN, PETEL B
Entity Type:Individual
Prefix:MRS
First Name:PETEL
Middle Name:B
Last Name:FAGAN
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 1:54 JENNIFER CIR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-3350
Mailing Address - Country:US
Mailing Address - Phone:585-754-3391
Mailing Address - Fax:
Practice Address - Street 1:54 JENNIFER CIR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606-3350
Practice Address - Country:US
Practice Address - Phone:585-754-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303492164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse