Healthcare Provider Details

I. General information

NPI: 1821431206
Provider Name (Legal Business Name): LANELL HAGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 BROADWAY N
FARGO ND
58102-1420
US

IV. Provider business mailing address

2800 BROADWAY N
FARGO ND
58102-1420
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-0221
  • Fax:
Mailing address:
  • Phone: 701-293-0221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH5285
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: