Healthcare Provider Details

I. General information

NPI: 1356169783
Provider Name (Legal Business Name): KRISTIN NICOLE HAGOPIAN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6805 STATE ROUTE 162
MARYVILLE IL
62062-8530
US

IV. Provider business mailing address

2734 VULLIET RD
HIGHLAND IL
62249-3840
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-5019
  • Fax:
Mailing address:
  • Phone: 618-801-8876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209030616
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: