Provider Demographics
NPI:1639922370
Name:FAGERLIE, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:FAGERLIE
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 1:24998 N 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-6325
Mailing Address - Country:US
Mailing Address - Phone:623-853-3428
Mailing Address - Fax:
Practice Address - Street 1:24998 N 74TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-6325
Practice Address - Country:US
Practice Address - Phone:623-853-3428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program