Basic Information
| Provider Information | |||||||||
| NPI: | 1255947974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAGAN | ||||||||
| FirstName: | ALICE | ||||||||
| MiddleName: | LORRAINE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1053 CENTER STREET | ||||||||
| Address2: | SC HOUSE CALLS INC | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004910909 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1053 CENTER STREET | ||||||||
| Address2: | SC HOUSE CALLS INC | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004910909 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2020 | ||||||||
| LastUpdateDate: | 11/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | AG03200068 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LF0000X | 24467 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.