Provider Demographics
NPI:1659977197
Name:BAGLEY, JEANETTE
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9906 154TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:BOWMAN
Mailing Address - State:ND
Mailing Address - Zip Code:58623-8829
Mailing Address - Country:US
Mailing Address - Phone:605-381-6420
Mailing Address - Fax:
Practice Address - Street 1:9906 154TH AVE SW
Practice Address - Street 2:
Practice Address - City:BOWMAN
Practice Address - State:ND
Practice Address - Zip Code:58623-8829
Practice Address - Country:US
Practice Address - Phone:605-381-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant