Provider Demographics
NPI:1669832556
Name:HAGEDORN, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HAGEDORN
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 1:1349 N MOUNT AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-1727
Mailing Address - Country:US
Mailing Address - Phone:573-334-9564
Mailing Address - Fax:573-334-1879
Practice Address - Street 1:1349 N MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-1727
Practice Address - Country:US
Practice Address - Phone:573-334-9564
Practice Address - Fax:573-334-1879
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110790363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology