Healthcare Provider Details

I. General information

NPI: 1093799132
Provider Name (Legal Business Name): LESLIE HAGENSTEIN DNP, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W 3RD STREET NEW PHYSICAL ADDRESS
MARBLETON WY
83113
US

IV. Provider business mailing address

PO BOX E 9615 HWY 191
PINEDALE WY
82941-3040
US

V. Phone/Fax

Practice location:
  • Phone: 307-276-3306
  • Fax: 307-276-3024
Mailing address:
  • Phone: 307-231-9562
  • Fax: 307-276-3024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8665.0048
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number340
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: