Healthcare Provider Details

I. General information

NPI: 1760126221
Provider Name (Legal Business Name): RANDI HAGEN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. RANDI EDENS

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9049 SPRINGBORO PIKE
MIAMISBURG OH
45342-4926
US

IV. Provider business mailing address

9049 SPRINGBORO PIKE
MIAMISBURG OH
45342-4926
US

V. Phone/Fax

Practice location:
  • Phone: 937-759-0545
  • Fax:
Mailing address:
  • Phone: 513-349-4027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.388342
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0032485
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: