Provider Demographics
NPI:1730131517
Name:FAGAN, AMY ELIZABETH (DPT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELIZABETH
Last Name:FAGAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 PROVIDENCE RD
Mailing Address - Street 2:SUITE 80
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4128
Mailing Address - Country:US
Mailing Address - Phone:757-467-1900
Mailing Address - Fax:757-467-7900
Practice Address - Street 1:4818 MARKET SQUARE LN
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4826
Practice Address - Country:US
Practice Address - Phone:804-744-3993
Practice Address - Fax:804-744-4301
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204357225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist