Provider Demographics
NPI:1902054331
Name:FAGRE, SHAELEEN M (AUD)
Entity Type:Individual
Prefix:DR
First Name:SHAELEEN
Middle Name:M
Last Name:FAGRE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SHEVLIN HALL
Mailing Address - Street 2:164 PILLSBURY DR SE
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-624-3322
Mailing Address - Fax:
Practice Address - Street 1:10564 5TH AVE NE
Practice Address - Street 2:#203
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-7200
Practice Address - Country:US
Practice Address - Phone:206-367-1345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
237600000X, 237700000X
CARPE5026231H00000X
CAHT8374237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHT 8374OtherSTATE CALIFORNIA DEPT. CONSUMER AFFAIRS HEARING AID DISPENSER
CARPE 5026OtherSPEECH LANGUAGE PATHOLOGY AUDIOLOGY BOARD