Provider Demographics
NPI:1790664142
Name:FAGAN, AMANDA M
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:FAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-4003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 DEPOT ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:IL
Practice Address - Zip Code:60424-9441
Practice Address - Country:US
Practice Address - Phone:815-557-0980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL000828467146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic