Provider Demographics
NPI:1144406380
Name:HAGGARD, MARY KATHRYN (RN, FNP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHRYN
Last Name:HAGGARD
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:HAGGARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, FNP
Mailing Address - Street 1:2510 DOUGLAS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3301
Mailing Address - Country:US
Mailing Address - Phone:916-773-1191
Mailing Address - Fax:916-773-0498
Practice Address - Street 1:2510 DOUGLAS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3301
Practice Address - Country:US
Practice Address - Phone:916-773-1191
Practice Address - Fax:916-773-0498
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA468668163W00000X
CA17870363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17870OtherBRN/NURSE PRACTITIONER
CA468668OtherBRN/REGISTERED NURSE
CAMH2008298OtherDEA