Provider Demographics
NPI:1174959183
Name:HAGEN, NIKKI LYNNE (NP)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:LYNNE
Last Name:HAGEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15953 AIME LN
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-9626
Mailing Address - Country:US
Mailing Address - Phone:847-623-2616
Mailing Address - Fax:
Practice Address - Street 1:15953 AIME LN
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:IL
Practice Address - Zip Code:60083-9626
Practice Address - Country:US
Practice Address - Phone:847-623-2616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.138021163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn