Provider Demographics
NPI:1619973997
Name:HAGEDORN, NICOLE ANNETTE (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNETTE
Last Name:HAGEDORN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 HENDERSON DR STE 5
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5297
Mailing Address - Country:US
Mailing Address - Phone:910-355-0442
Mailing Address - Fax:
Practice Address - Street 1:2680 HENDERSON DR STE 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5297
Practice Address - Country:US
Practice Address - Phone:910-355-0442
Practice Address - Fax:910-355-0443
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
NC78537207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty