Healthcare Provider Details

I. General information

NPI: 1477038560
Provider Name (Legal Business Name): NICOLLE HAGEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7115 FORTHUN RD # 115
BAXTER MN
56425-8597
US

IV. Provider business mailing address

7115 FORTHUN RD
BAXTER MN
56425-8597
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-3529
  • Fax:
Mailing address:
  • Phone: 218-829-9307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9394
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number206130-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: