Healthcare Provider Details

I. General information

NPI: 1144406380
Provider Name (Legal Business Name): MARY KATHRYN HAGGARD RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MOLLY HAGGARD RN, FNP

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 DOUGLAS BLVD STE 200
ROSEVILLE CA
95661-3301
US

IV. Provider business mailing address

2510 DOUGLAS BLVD STE 200
ROSEVILLE CA
95661-3301
US

V. Phone/Fax

Practice location:
  • Phone: 916-773-1191
  • Fax: 916-773-0498
Mailing address:
  • Phone: 916-773-1191
  • Fax: 916-773-0498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number468668
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: