Healthcare Provider Details

I. General information

NPI: 1629646567
Provider Name (Legal Business Name): MARLEE N HAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARLEE N LANDON

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FOUNDERS LN STE 100
JACKSONVILLE IL
62650-3924
US

IV. Provider business mailing address

15 FOUNDERS LN STE 100
JACKSONVILLE IL
62650-3924
US

V. Phone/Fax

Practice location:
  • Phone: 217-243-0300
  • Fax: 217-862-0202
Mailing address:
  • Phone: 217-243-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.023504
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: