Basic Information
| Provider Information | |||||||||
| NPI: | 1477531077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGIE | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAGIE | ||||||||
| OtherFirstName: | SUE | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 RANDOLPH ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216291243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104794306 | ||||||||
| FaxNumber: | 4104791714 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 RANDOLPH ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216291243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104794306 | ||||||||
| FaxNumber: | 4104791714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024164940 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | R039951 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 521116591 | 01 | MD | COVENTRY | OTHER | 521116591 | 01 | MD | TRICARE | OTHER | T5880041 | 01 | MD | CF BC/BS GRP/GHMSI/BL CHO | OTHER | 521116591 | 01 | MD | NCPPO | OTHER | 89623401 | 01 | MD | CAREFIRST BC/BS RENDERING | OTHER | 206378 | 01 | MD | PRIORITY PARTNERS | OTHER | 521116591 | 01 | MD | INFORMED | OTHER | 521116591 | 01 | MD | CIGNA | OTHER | 784381000 | 05 | MD | MEDICAID | 521116591 | 01 | MD | MARYLAND PHYSICIANS CARE | OTHER |