Provider Demographics
NPI:1396415857
Name:FAGAN, MACKENNA G
Entity Type:Individual
Prefix:MRS
First Name:MACKENNA
Middle Name:G
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 1:443 SUMNER RD
Mailing Address - Street 2:
Mailing Address - City:CORFU
Mailing Address - State:NY
Mailing Address - Zip Code:14036-9566
Mailing Address - Country:US
Mailing Address - Phone:585-409-0693
Mailing Address - Fax:
Practice Address - Street 1:4362 GRIDER RD
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:NY
Practice Address - Zip Code:14059
Practice Address - Country:US
Practice Address - Phone:716-652-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008973224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant