Provider Demographics
NPI:1477024206
Name:FAGAN, BOBBI LYNN (PEER SPECIALIST)
Entity type:Individual
Prefix:MS
First Name:BOBBI
Middle Name:LYNN
Last Name:FAGAN
Suffix:
Gender:F
Credentials:PEER SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4006 IDA ST
Mailing Address - Street 2:ALPHA LIFE
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68112-0257
Mailing Address - Country:US
Mailing Address - Phone:531-207-6462
Mailing Address - Fax:402-999-4786
Practice Address - Street 1:415 SOUTH 25TH AVE
Practice Address - Street 2:ANNEX BLD
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131
Practice Address - Country:US
Practice Address - Phone:402-715-4226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE52521376K00000X
NECPSS-305175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE01520101901Medicaid
NE52521OtherPUBLIC HEALTH
NE441934OtherACCESS NE