Provider Demographics
NPI:1013167402
Name:FAGAN, DEVONA L (NP)
Entity Type:Individual
Prefix:MRS
First Name:DEVONA
Middle Name:L
Last Name:FAGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 ADAMS BLVD
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-2235
Mailing Address - Country:US
Mailing Address - Phone:702-293-0406
Mailing Address - Fax:702-293-0192
Practice Address - Street 1:895 ADAMS BLVD
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-2235
Practice Address - Country:US
Practice Address - Phone:702-293-0406
Practice Address - Fax:702-293-0192
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP17793163WE0003X
CA17793363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WE0003XNursing Service ProvidersRegistered NurseEmergency