Healthcare Provider Details

I. General information

NPI: 1144547209
Provider Name (Legal Business Name): NICOLE MARIE HAGLUND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

IV. Provider business mailing address

4160 ZELLER CT
DIAMOND SPRINGS CA
95619-9201
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9240
  • Fax:
Mailing address:
  • Phone: 530-919-5242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number9291
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: