Healthcare Provider Details

I. General information

NPI: 1174007215
Provider Name (Legal Business Name): BROOKLYN LYNN HAGAN BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BROOKLYN LYNN HAGAN BS

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 BRECKENRIDGE ST
OWENSBORO KY
42303-1054
US

IV. Provider business mailing address

1501 BRECKENRIDGE ST
OWENSBORO KY
42303-1054
US

V. Phone/Fax

Practice location:
  • Phone: 270-686-5982
  • Fax:
Mailing address:
  • Phone: 270-686-5982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: