Provider Demographics
NPI:1851545438
Name:FAGAN, KELSEY HEATHER
Entity Type:Individual
Prefix:MS
First Name:KELSEY
Middle Name:HEATHER
Last Name:FAGAN
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 1:1327 KEOLU DR
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4113
Mailing Address - Country:US
Mailing Address - Phone:360-961-2047
Mailing Address - Fax:
Practice Address - Street 1:91-2301 OLD FT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-3602
Practice Address - Country:US
Practice Address - Phone:808-671-8511
Practice Address - Fax:808-677-2525
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist