Basic Information
| Provider Information | |||||||||
| NPI: | 1902453418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAGAN | ||||||||
| FirstName: | SHERILYN | ||||||||
| MiddleName: | LYDIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 286 EUCLID AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921143611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192662111 | ||||||||
| FaxNumber: | 6192660496 | ||||||||
| Practice Location | |||||||||
| Address1: | 286 EUCLID AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921143611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192662111 | ||||||||
| FaxNumber: | 6192660496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2019 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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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 | 163W00000X | 577368 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.