Provider Demographics
NPI:1629307194
Name:HAGAN, ANGIE LE'ALICE (CPM, CNP)
Entity Type:Individual
Prefix:MS
First Name:ANGIE
Middle Name:LE'ALICE
Last Name:HAGAN
Suffix:
Gender:F
Credentials:CPM, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 S LIME ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-6207
Mailing Address - Country:US
Mailing Address - Phone:575-538-2981
Mailing Address - Fax:855-653-5171
Practice Address - Street 1:1511 S LIME ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-6207
Practice Address - Country:US
Practice Address - Phone:575-538-2981
Practice Address - Fax:855-653-5023
Is Sole Proprietor?:No
Enumeration Date:2009-12-13
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02963163WG0000X, 363LP2300X
NM02431R176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No176B00000XOther Service ProvidersMidwife