Provider Demographics
NPI:1942842398
Name:FAGAN, MCKENZIE CHRISTINE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:CHRISTINE
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 1:105 SEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19127-1811
Mailing Address - Country:US
Mailing Address - Phone:724-372-9269
Mailing Address - Fax:
Practice Address - Street 1:105 SEVILLE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19127-1811
Practice Address - Country:US
Practice Address - Phone:724-372-9269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA94620632255R0406X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255R0406XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistRehabilitation, Blind