Basic Information
| Provider Information | |||||||||
| NPI: | 1992708671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGEMANN | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, APRN, BC FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEWLETT | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSN, APRN, BC FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 420 N. 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082630450 | ||||||||
| FaxNumber: | 2089622313 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 LEWISTON ST | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835229750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089623267 | ||||||||
| FaxNumber: | 2089622313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP300A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 804211800 | 05 | ID | MEDICAID |