Healthcare Provider Details

I. General information

NPI: 1962979401
Provider Name (Legal Business Name): JODY ANN HAGAN RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HITCHCOCK WAY
MANCHESTER NH
03104-4125
US

IV. Provider business mailing address

32 CLARK MILL RD
WEARE NH
03281-4608
US

V. Phone/Fax

Practice location:
  • Phone: 603-645-6401
  • Fax: 603-629-8654
Mailing address:
  • Phone: 603-660-9652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number439
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: