Provider Demographics
NPI:1508928920
Name:FAGAN, KELLY ANNE (NPP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OLDE EASTWOOD VILLAGE BLVD
Mailing Address - Street 2:APARTMENT 213
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-1680
Mailing Address - Country:US
Mailing Address - Phone:585-259-5272
Mailing Address - Fax:
Practice Address - Street 1:90 ASHELAND AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4021
Practice Address - Country:US
Practice Address - Phone:828-254-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400995-1363LP0808X
NYF381648-1363LP0200X
NC229768363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03240911Medicaid
NYJ400168230Medicare PIN