Provider Demographics
NPI:1912421496
Name:FAGAN, DAWN MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 E HENRIETTA RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-3921
Mailing Address - Country:US
Mailing Address - Phone:585-775-6673
Mailing Address - Fax:
Practice Address - Street 1:750 E HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1406
Practice Address - Country:US
Practice Address - Phone:585-775-6673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258797164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse