Provider Demographics
NPI:1568188100
Name:FAGAN, VIRGINIA SUE
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:SUE
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 1:29 RESTER RD
Mailing Address - Street 2:
Mailing Address - City:PERKINSTON
Mailing Address - State:MS
Mailing Address - Zip Code:39573-4947
Mailing Address - Country:US
Mailing Address - Phone:228-343-3105
Mailing Address - Fax:
Practice Address - Street 1:29 RESTER RD
Practice Address - Street 2:
Practice Address - City:PERKINSTON
Practice Address - State:MS
Practice Address - Zip Code:39573-4947
Practice Address - Country:US
Practice Address - Phone:228-343-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X
MS3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion