Provider Demographics
NPI:1942954169
Name:HAGERTY, CAROLYN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:HAGERTY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 VISA DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2131
Mailing Address - Country:US
Mailing Address - Phone:309-268-9000
Mailing Address - Fax:
Practice Address - Street 1:1603 VISA DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2131
Practice Address - Country:US
Practice Address - Phone:309-268-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2029.024736363L00000X
IL209.024736363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner