Healthcare Provider Details

I. General information

NPI: 1164344313
Provider Name (Legal Business Name): DANIELLE SHAE HAGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 BROADWAY N STE 2
FARGO ND
58102-1439
US

IV. Provider business mailing address

3372 39TH ST S
MOORHEAD MN
56560-6917
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-3231
  • Fax: 701-232-5013
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberV332272301908
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: