Provider Demographics
NPI:1972098697
Name:FAGAN, COURTNEY (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6316 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3364
Mailing Address - Country:US
Mailing Address - Phone:262-752-7240
Mailing Address - Fax:
Practice Address - Street 1:3805 SPRING STREET
Practice Address - Street 2:BLDG A - SUITE 311
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1600
Practice Address - Country:US
Practice Address - Phone:262-687-6345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI184877-30163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator