Healthcare Provider Details

I. General information

NPI: 1780072983
Provider Name (Legal Business Name): MARCIA HAGBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 E FLAMINGO RD
LAS VEGAS NV
89119-5249
US

IV. Provider business mailing address

1640 E FLAMINGO RD
LAS VEGAS NV
89119-5249
US

V. Phone/Fax

Practice location:
  • Phone: 725-400-2515
  • Fax:
Mailing address:
  • Phone: 725-400-2515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN75384
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: