Basic Information
| Provider Information | |||||||||
| NPI: | 1003205576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAGAN | ||||||||
| FirstName: | MELODIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 N COLUMBUS ST | ||||||||
| Address2: | |||||||||
| City: | CRESTLINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448271455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194680935 | ||||||||
| FaxNumber: | 4194625372 | ||||||||
| Practice Location | |||||||||
| Address1: | 139 GAIUS ST | ||||||||
| Address2: | |||||||||
| City: | BUCYRUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448201508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195639855 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2015 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA.16997-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0117339 | 05 | OH | MEDICAID |