Provider Demographics
NPI:1336354851
Name:HAGEMAN, CONSTANCE (RD,LN)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:HAGEMAN
Suffix:
Gender:F
Credentials:RD,LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CUMMINGS AVE., SW
Mailing Address - Street 2:BOX 415
Mailing Address - City:HIGHMORE
Mailing Address - State:SD
Mailing Address - Zip Code:57345-0415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 CUMMINGS AVE., SW
Practice Address - Street 2:BOX 415
Practice Address - City:HIGHMORE
Practice Address - State:SD
Practice Address - Zip Code:57345-0415
Practice Address - Country:US
Practice Address - Phone:605-852-2112
Practice Address - Fax:605-852-2243
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0040133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8HD745Medicare UPIN