Provider Demographics
NPI:1659007599
Name:FAGER, MARY LYNN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:FAGER
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 1:7785 N STATE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-1229
Mailing Address - Country:US
Mailing Address - Phone:315-376-5453
Mailing Address - Fax:
Practice Address - Street 1:7395 EAST RD
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-1590
Practice Address - Country:US
Practice Address - Phone:315-376-9701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator