Provider Demographics
NPI:1790843407
Name:HAGEN, ELAINE A (RD, CD)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:A
Last Name:HAGEN
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660376
Mailing Address - Street 2:EGH INSURANCE PAYMENTS
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46266-0376
Mailing Address - Country:US
Mailing Address - Phone:574-523-3148
Mailing Address - Fax:574-523-3492
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:NUTRITION SERVICES DEPARTMENT
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-523-3236
Practice Address - Fax:574-296-6504
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN727380133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN940230FMedicare PIN