Provider Demographics
NPI:1407005333
Name:HAGNER, KIMBERLY (ARNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HAGNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-3128
Mailing Address - Country:US
Mailing Address - Phone:712-328-5102
Mailing Address - Fax:
Practice Address - Street 1:800 MERCY DR
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3128
Practice Address - Country:US
Practice Address - Phone:712-328-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA110707363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI9291010Medicare PIN