Provider Demographics
NPI:1053649574
Name:HAGENAUER, KATHLEEN JO (APN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JO
Last Name:HAGENAUER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:KAHTLEEN
Other - Middle Name:JO
Other - Last Name:MOERSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:309-655-2000
Mailing Address - Fax:309-655-7480
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-2000
Practice Address - Fax:309-655-7480
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007387363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care