Provider Demographics
NPI:1821860461
Name:VANDERHAEGEN, MCKENNA
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:VANDERHAEGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MCKENNA
Other - Middle Name:
Other - Last Name:VAN DER HAEGEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4169 GOSSAMER ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-4893
Mailing Address - Country:US
Mailing Address - Phone:916-412-9235
Mailing Address - Fax:
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:916-784-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95268949163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse