Provider Demographics
NPI:1689016867
Name:FAGAN, LAUREN MICHELLE (CRNA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELLE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E 19TH ST
Mailing Address - Street 2:APT 5S
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-2127
Mailing Address - Country:US
Mailing Address - Phone:404-353-6594
Mailing Address - Fax:
Practice Address - Street 1:FILE 4501
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90074-0001
Practice Address - Country:US
Practice Address - Phone:503-372-2740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY642458163W00000X
CA95089753367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse