Provider Demographics
NPI:1790976843
Name:HAGENBERGER, MARIA S (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:S
Last Name:HAGENBERGER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 NORTHWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-4668
Mailing Address - Country:US
Mailing Address - Phone:631-272-5250
Mailing Address - Fax:
Practice Address - Street 1:107 NORTHWOOD BLVD
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-4668
Practice Address - Country:US
Practice Address - Phone:631-272-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111380-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02144907Medicaid