Basic Information
| Provider Information | |||||||||
| NPI: | 1629307194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGAN | ||||||||
| FirstName: | ANGIE | ||||||||
| MiddleName: | LE'ALICE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CPM, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1511 S LIME ST | ||||||||
| Address2: | |||||||||
| City: | DEMING | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880306207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755382981 | ||||||||
| FaxNumber: | 8556535171 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 S LIME ST | ||||||||
| Address2: | |||||||||
| City: | DEMING | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880306207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755382981 | ||||||||
| FaxNumber: | 8556535023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2009 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | CNP-02963 | NM | N | Nursing Service Providers | Registered Nurse | General Practice | 176B00000X | 02431R | NM | N | Other Service Providers | Midwife | 363LP2300X | CNP-02963 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.