Provider Demographics
NPI:1477038560
Name:HAGEN, NICOLLE (APRN)
Entity Type:Individual
Prefix:
First Name:NICOLLE
Middle Name:
Last Name:HAGEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7115 FORTHUN RD
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8597
Mailing Address - Country:US
Mailing Address - Phone:218-829-9307
Mailing Address - Fax:
Practice Address - Street 1:7115 FORTHUN RD # 115
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8597
Practice Address - Country:US
Practice Address - Phone:218-829-3529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9394363LP0808X
MN206130-6163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health