Provider Demographics
NPI:1548558968
Name:HAGERTY, MARYLYN A (DNP FNP)
Entity Type:Individual
Prefix:MS
First Name:MARYLYN
Middle Name:A
Last Name:HAGERTY
Suffix:
Gender:F
Credentials:DNP FNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1808 CALLE MAYITA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-2306
Mailing Address - Country:US
Mailing Address - Phone:949-933-2620
Mailing Address - Fax:949-361-5092
Practice Address - Street 1:12900 PARK PLAZA DR STE 150
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703
Practice Address - Country:US
Practice Address - Phone:562-229-4831
Practice Address - Fax:949-305-8520
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA267941163WH0200X
CA21337364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No163WH0200XNursing Service ProvidersRegistered NurseHome Health