Basic Information
| Provider Information | |||||||||
| NPI: | 1851545438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAGAN | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | HEATHER | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1327 KEOLU DR | ||||||||
| Address2: | |||||||||
| City: | KAILUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967344113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609612047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 91-2301 OLD FT WEAVER RD | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967063602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086718511 | ||||||||
| FaxNumber: | 8086772525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2008 | ||||||||
| LastUpdateDate: | 11/10/2008 | ||||||||
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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 | 221700000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist |
No ID Information.