Provider Demographics
NPI:1316195183
Name:FAGAN, ALVINA (LPN)
Entity Type:Individual
Prefix:MS
First Name:ALVINA
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HEWITT LN APT 4
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-5444
Mailing Address - Country:US
Mailing Address - Phone:845-562-2077
Mailing Address - Fax:
Practice Address - Street 1:701 HEWITT LN APT 4
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-5444
Practice Address - Country:US
Practice Address - Phone:845-562-2077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128466-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY008644846Medicaid