Provider Demographics
NPI:1659454692
Name:HAGAN, KIMBERLY L (ARNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:HAGAN
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 1:411 W INDIANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-3538
Mailing Address - Country:US
Mailing Address - Phone:561-746-7811
Mailing Address - Fax:
Practice Address - Street 1:411 W INDIANTOWN RD
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-3538
Practice Address - Country:US
Practice Address - Phone:561-746-7811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1896942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE3744ZMedicare ID - Type UnspecifiedMEDICARE KIM HAGAN ARNP
FLP01167Medicare UPIN