Provider Demographics
NPI:1114128717
Name:VON HAGEN, JOAN (SLP)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:
Last Name:VON HAGEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5079 N DIXIE HWY
Mailing Address - Street 2:#292
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4000
Mailing Address - Country:US
Mailing Address - Phone:714-321-9508
Mailing Address - Fax:
Practice Address - Street 1:9929 RACE TRACK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4458
Practice Address - Country:US
Practice Address - Phone:866-416-5199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2531314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility