Provider Demographics
NPI:1578012126
Name:HAGY, FALLON
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:
Last Name:HAGY
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 1:7332 WYOMING TRL
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-9343
Mailing Address - Country:US
Mailing Address - Phone:717-327-6574
Mailing Address - Fax:651-408-9303
Practice Address - Street 1:7332 WYOMING TRL
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-9343
Practice Address - Country:US
Practice Address - Phone:717-327-6574
Practice Address - Fax:651-408-9303
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1082496172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker