Provider Demographics
NPI:1295055242
Name:FAGAN, SHERYL DIANE (ARNP)
Entity type:Individual
Prefix:MS
First Name:SHERYL
Middle Name:DIANE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4928
Practice Address - Street 1:4211 VAN DYKE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8005
Practice Address - Country:US
Practice Address - Phone:813-264-6490
Practice Address - Fax:813-443-8143
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1662752363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002400000Medicaid
FLDL813ZMedicare PIN