Healthcare Provider Details

I. General information

NPI: 1588366637
Provider Name (Legal Business Name): NICOLE MICHELLE HAGGERTY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 NATIONAL AVE
SAN DIEGO CA
92113-2209
US

IV. Provider business mailing address

400 W MINERAL KING AVE
VISALIA CA
93291-6237
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2382
  • Fax:
Mailing address:
  • Phone: 559-624-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA204157
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number12075
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: