Healthcare Provider Details

I. General information

NPI: 1184731671
Provider Name (Legal Business Name): SANDY R HAGENE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 OZARK DR
CUBA MO
65453
US

IV. Provider business mailing address

102 OZARK DR STE B
CUBA MO
65453-1664
US

V. Phone/Fax

Practice location:
  • Phone: 573-885-6600
  • Fax: 573-885-6610
Mailing address:
  • Phone: 573-885-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number112906
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: