Basic Information
| Provider Information | |||||||||
| NPI: | 1295055242 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAGAN | ||||||||
| FirstName: | SHERYL | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | A.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10744 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337578744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275320002 | ||||||||
| FaxNumber: | 7272664928 | ||||||||
| Practice Location | |||||||||
| Address1: | 4211 VAN DYKE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335588005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132646490 | ||||||||
| FaxNumber: | 8134438143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2010 | ||||||||
| LastUpdateDate: | 07/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP1662752 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 002400000 | 05 | FL | MEDICAID |