Provider Demographics
NPI:1386180388
Name:FAGERLIE, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:FAGERLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8724
Mailing Address - Country:US
Mailing Address - Phone:701-237-9977
Mailing Address - Fax:701-237-6797
Practice Address - Street 1:825 25TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8724
Practice Address - Country:US
Practice Address - Phone:701-237-9977
Practice Address - Fax:701-237-6797
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2794237700000X
NDH-0346237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist